19813 APPLICANT TO FILL IN INFO RMATION.WITH IN'RED LINES— USE BALL POINT PEN ONLY
Building Prom Identification PELMITNO.
Building Address: 1 9 8 1 3
og3a Q. vy-
came: Phone:
�er. r) VLV. 'D - CITY OF CUPERTINO-BUILDING DIVISION
e�nnn<��na�nr. came Lk.No: APPLICATION I PERMIT r ) - \ 'qD
BUILDINGELECTRICA PLUMBING-MECHANICAL CATEGORYCONTROL
Architect/Engine. Lk. o
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. ��PERMITISSUANCE I ❑ El F-1LICENSED CONTRACTOR'S DECLARATION
I lath b ion7Oaffirm,thatfDtmsicrnrefth dB. .ro...nsoffe son C(mmmrne- APPITANCFSRESIDENML JO DFSCRB'770N
Ingwith Section 7W0)ofd diedn3o(the Butlnemand Pro(eWonaCode,and my
Iicenm laiefull force and—LIC.If PANES
LicenDate Clam Lic,p
Date.Contractor -,UK
ARCHITECT'S DECLARATION 201-1000 AMPS
p�p�uu a0 Q I understand my plans shall be used u public records. OVER 1000 AMPS SQ.FT. R AREA S/SQ.F9.
biz Licensed Professimal ECNS ELECTRICAL I N
6 rg OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M
z Iherebyaffl mthat lam ezemp fromthe Contractors License Law feethe
pp following reason.(Section 7035,Business and Professions Code:My city or
FE ty cauntywhkhrequU aper tWcomtmcctaller,lmpmve,demollah,ormpalr �MP'METER OR POL
m '3 any strurmre prior to its Issuance,also requires the a ppllant for such permit to POWER DEVICES- O
a0 6 file a signed abutment that M Is licensed pursuant to the provisions of theDATE
u,lin Contractor's License law(Chapter9(commencing with Section 7000)of Divl- VALUATION OS cI.n3 of the Business and Professions Code)orthat he Is exempt therefrom and SWIMMING PODL C
the basis for the alleged exemption. Any violation of Section 70315 by any
p applicant/ora permit subjectstheapplicanttoa Civil penalty ofnat nrethan OU'ILELSSWITCHESHKTURES
n
five hundred a sr owner of the property,
NEW RESIDENTIAL ELECIR SQ.FIL STORIES TYPE CONSTRUCTION
❑I,as owner of Ilse property,or my employes with wagon as offered
sale - `
7< Ole(Se
compensation,Businessl do and
Prwork,and the ssions structure h Contraonlistended or cense Lar
D sale(Sec.7044,to anowandf property Code;The Comranors I hemon law _ 1
docs does
apply torn irmadner ofpropgh hi.m .em who oy.,pr nlMreon,and OCC.GROUP RFS.UMTS
EE
who doementsa not
tintendedcrwgh hhownemp,howev calashovided ildinghat r
improvementsarenmintended earofco foraek.If,however, oder i)iWve TOTAL:
Improvement Isaold withinoney.arolcompletlon,tMowner-bu0derwill have � - a
ttill.korden of proving that M did not build or improve for purpose of sale.). QTY, PLUMBINGPERMIT FEE FLOODZANE APN
Lj 4 as owner of the property,am exclusively mmncbng with licensed PERMIT ISSUANCE -
contractors to construct the project(Sec.7W4,Business and Pmf ssions Code:
The Contractors License Law does not apply to an owner of property who ALTERDRAIN kVENT-WA'fpt[FA)
Wor improves thereon, and who contracts -
fee such Toplacts with a - FEE SUMMARY
,xiaLpetor(s)licensed pursuant to the ContractorFL
Contractor's Llmn.o Law. BACK AW PROTECT.DEVICE
1_J I am exempt under Sec. R k P C for this reason
OUTSIDE FEES
DRAINSFLOOKROOP,AREA,CONTI. SANITARY Y N_
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION FATURE&PER TRAP SCHOOL TAX Y N
❑I horeby or( r.that I have o lmumne of consent d spythmre,ora RECEIPT p
certificate of Workera'Compersatlonlwunnce ma certified spy thereo!(Seo.
3500,Lab CJ GAS EA.5YSTEM-1 INCA OUTLETS PARK FEE Y N
' RECEIPTN
Policy p GAS-F.A.SYSTEM-OVER 4(EA)
Ca���������m000000any BUILDING DIVISION FEES
C.
ed spy is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200FT. Date RL'Cel t#
(ThlaaecEm need net M completed if thepermit Islorom hundred dollars
(9100)orlem.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of thework forwhich this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING Wokers'Compensaticn❑Wsof Callfornla.Date PAID
-
z Z Applicant NEW RESIDENTIAL PI.MB, SQFT. Date RST!E!#
Z O NOTICETO APPLICANT.If,after trading this Certificate of Exemption,you
should become mbfect to the Worken'Comperwtion provisions of the Labor TOTAL:
CC N Code,you at forthwith comply with such provisions orthis permit shall be I
W > deemed revoked. '
EE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffirm that there I .centimeter,lendingagency forthe perform- TOTAL: ELECTRIC FEE
D Z ance ofthe work ferwhich this permit is Wood(See3097,Ci¢CJ
V O Lender's Name PLUMBING FEE
LL H lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1cotilythat l have read thlsapplicatienand slatethattheaWve Information
(LI WI, l ageeeto comply with all dtyand county ordinances and state laws PERMITISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives ofthIs
F N city to enter upon the aMve-mentloned property for inspection purposes. ALTERORADDTOMECH.
Z Date Recei t#
_ (We)agree to rove,IndemNfyandkeepharmless es whihthe City o/Cupertlna
against lBbllitke,Judgmenla,roateand expense which may in anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Wt said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the app0ant orfutum building occupant store or handle hazardous HEATING UNIT(TO 100,01O BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Fl❑YedSafety Code SSecton75532(¢)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: Z.C�
Will the x ppilcant or future building occupant use eiulperenl or devices VENTILATION rAN(SINGLE RESID) ISSUANCE DATE
which emit hazardoua air contaminant.as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,010 BTU) -
❑Ya ❑No
I have read the hazardous materials requirements under Chapter G95 of BOILER-COMP(OVER IWM BTU)
the Califomla Health k SafetyCode,Sections 25505,25533 and 25534.I t
understand that lithe building does net currently have a tenant,that it b"my NEW RESIDENTIAL MECH. 9Q.FT �]!1
responsibility to notify the ce.Team of the requirements which must be ort
prior to issuance of a Certificate of Occupancy. '^'TT..,,����++ �� -r.�� �,,.. {
(Tuner or authodred agent Date - ISSUED BY q)S— RtX N�"`+�M
TOTAL:
OFFICE COPY