19850 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru:ea Identification PERMIT NO.
Building Add was: 19850 Q C 0
o� El M oVo , Ccl, o JUJ
hers ares: C Z P aft
6 CITY OF CUPERTINO-BUILDING DIVISION A A
Contractor's Na Qq
me: Ie.No APPLICATION / PERMIT
Gf/ O V BMLDING-ELECMCALPLUMBING-MECHANICAL CATEGORY CONTROL X
Amhi /Engimier. Lk No:
/,�� p C ` QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:0 9FRA7caaA—SCVK * II DI JiyJa PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRAC'OR'SD LARATION
I hereby affirm that l am licensed under proviatonsaf Chapter 9(coman enc APPLIANCES JOB DESCRIPTION
Ingwith Scdton7000)of Dividon3 oftheBusinessand PmfentonsCode,and m
license is in full force a dctfect. PANELS
Ltccmc Class Lic.X - o z!K
Date Contractor v MG— UPTO200AMPS �U G
ARCHITECTSDECLARATION
N CO I understand my plans shall be used as public records.
OVER 1000 AMPS SQ.FC.FLOOR FA E/SQ.FT.
NO Licensed Professimal SIGNS ELECTRICAL
G cc OWNER-BUILDER DECLARATION SPECIALCItCI!ET/ fi ^ Ij P"� pps�Iy1
L., lherobyaffirenthatlamexemptfromlhe Contractm'.Ltomse Lawforthe I V
Oy following reason.(Section 7011.5,Business and Professions Code:Any city or TEMP.ME ER OR LE INST.
F county which requires a permit to construct,alter,Impmv%dennlish,or repair 6
gF�4�< any stmeture prior to its issuance,also require the applicant for such permit to POWER DEVICES
F-ga�U file a signed statement that he Is licensed pursuant to the provisions of the J0
5]OE� Contractor's License LawSection(Chapter 9(commeneing with Sion 7000)of Divi- SWIMMING POOL ELECCRIC -_ VALUATION
til30 sion3of the Business and ProfemiomCode)or that he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWI FIESF7XIVRFS -
{.r,a+ <+
applicant fora permit subjects the appllcanito a civil penalty of not more than
c. five hundred dollars(1500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
7 ❑I,as owner of the property,or my employees with wages es their sole
mmpeosation,will dothe work,and thestructure is not Intended or offered for
psale(Sec.7044,Business and Professions Code:The Contractors License law
$ docs not apply to an owner of property who Wilds or improves thereon,and OCG GROUIP RFS.UNITS
n.$^ who don such work himself or through his own employees,provided that such
Improvements are not intended or offered for sale.If,however,the Wilding or TOTAL:
Improvement is sold within one year ofoomplelion,the owner-budderwlll have
tiffrden of proving that he did not Wed or Improve for pu rpos,of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PFRMITISSUANCE
contractors to construct the project(Sec.7044 Business and Profession Code:
The Contractor's License law don not apply to an owner of property who ALTER-DRAW&VFM-WATER(EA)Wilde or Improves thereon, and who contracts for such pi jem with a FEE SUMMARY
cg6[Cactor(a)licensed pursuant to the Contractor's License Law. BACX F(OWPROTFOT.DEVICE
L�I am exempt under Sec B& P C for this reasonOUTSID17 FEES
DRAINS FLOORROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT X
WORKMAN COMPENSATION DECLARATION .� FIXTUTil PER TRAP � SCI{OOLTAX Y_ N_
M1 hereby affirm that 1 have a certificate of consent to self-incurs,ora RECEIPT X
certificate of Workers'Compensation Insurance or a certified copythereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.)
— RECEIPT X
Policy X GAS EA.SYSTEMOVER 4(FA) BUILDING DIVISION FEES
Cam any
MrI Pied copy 6 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
WCertified copy is filed with the city inpectlon division.
CERTIFICATE OF EXLTIITION FROM WORKERS' GREASE TIW' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Reoef t#
(Thbsedion need not be completed tithe permit isfor ane hundred dollars
($1 W)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that to the performance of the work for which this permit is hsued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Work rsCompemeationlawsof Califomb.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.FI.
Z O Date Recei t#
NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
VI Code,you must forthwith comply with such provision orthisfcmul shall W BUILDING FEE
W 9 deertM revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
I mirsNhereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
a
0 Z aurn o(.the Nwork!car which this permitisissued(Sec.3097,Civ.C.) TOTAL:
U O Ieeame PLUMBING FEELL 3 Lp
F- Lenders Address QTY. MECHANICAL PERMIT FEE
O W Imrtllythatlhavereadth appbcatlonandstatethattheaWve information MECHANICAL FEE
1 lacormet.I agembi comply with all city and countyordlnaremve d state laws PERMIT ISSUANCE FEES PAI D:
relatI ng to building construction,and hereby authorize representatives of this
H U)city to enter upon the abowmentioned property for inspection pu rposes, ALTER OR ADD TO MECH.
(We)ago to save,indemrdly an d keep harmless the City of Cu ped Inca Date Receipt#
V agamet liabilities,Pigments,costs a nd expenses which may In any way scone AIR HANDLING UNIT(C010,0DB CFM) SUBTOTAL:
agaimt mid City in consequen fthegrantingofthie rmit.
I �f! AIRHANDLINGUMT(OVERIO,000CIM) CONSTRUCTION TAX
Signature o(ApplContractor Date IXHAI)5'C fI00D(W/DIKT) CONSTRUCTION TAX PAID:
HA
HAZARDOUS MATERIALS DISCLOSURE
Wlathe aefin cad y the
rcrtinobuilding Municipal
ode, hhandlehazardous HEATINGUMT(TO 100,000 BTU) Date Recef t#
material and
definedby the Cupertino 255 Munldpal Code,Chapter 9.12,and the
I{calth and Safely Code Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
M Yea lryg No
Will the applicant oUuwm Wilding occupant use equipment or devices VENTILATION FAN SINGLE RFSID) ISSUANCE DATE
wh lch emit hams ore air conn minants as defined by the Bay Area Air ®/I nr�s
Quality Management 1 rict2 BOILER-COMP QHP OR 100,000 BTU) �a.0"
Yes No
` 1have read theh mus materials requlrereents under Chapter 6.95 of BOILER-COMP(OVERIM.000 BTU) ABR X
( the California Health&Safety Cod,Sections 25505,25533 and 25SM.1 firlY 79,9U
• understand that if the building does not currently have a tenant,that it is my NEW RESI DENIIAL MECH. SQ3TT.
responsibility to net lfy the occupant of the mqu imments which must be met G��,
prior to issuance q(a file Omppaan�`'.e -�V Of('dI HAr� (J 7L—S�l
Owner or authgri:ed agent Date TOTALISSUED BY:�`'
:
OFFICE COPY