19456 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 1
Building o' Identification Nu PI:f6hgTN 1 9 4 5 6
BuildingAddress:
JOALI-A 1&
e: Phe: p A A
%hilectla
^ 'LT+ onCITY OF CUPERTINOBUILDING DIVISION
" Na Me.No: APPLICATION I PERM
IT b� I
gineer: Uc.No: BUILDINC-M, C RICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL X
QTY ELECTRIC PERMIT FEE BUILDINCPERMIT INFO
Address: PERMITISSUANCE (`� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirmtivt l amisonsed under protalmosof Chapter9(comment APPLIANCESRESIDENUAL JOB DFSCRga'HON
ingwith Sc"Ion7DOD)of DiWsian3ofthe Bus---sand Pmfessions Code,and my
license Is i (u d affect 1 PANELS L�c0 ��
Llmnse.111��.f LION
Datel�ly Cmdra"ar_
�1t{qiizRCHITE! S EC R 201-IODOAMPS
mO X I understand my plans shag co
be used as public records. OVER IOOO AMPS SQ.FT.FLOOR AREA S/SQ.FT_..
m U o Licensed Professional SIGNSELECTRICAL
6 cW.
OWNER. OLDER DECLARATION SPECIAL CIRCNT/MISC
y � herebyaffi mthatI amexempt form the Contractors License Lawforthe
following reason.(Section 70115,Business and Pnefrninns Code:Any city or
F t'� county which requiresa permit W orratruct,alts,improve,demolish,orrepair TEMPMETER OR POLE INST.
anystmctumpdartoim6 ame,alsorequ6nrheappliantforsuchpermit to
O4 file a signed statement that he h licensed pursuant to the pmvhume of the POWER DEVICES -
3Oson3 fhesBulcense slnnaf rad Professioru Coder 9 neMorlhaghe]sewith x coir,(hes 0ere�from�nd SWIMMING POOL ELECTRIC VALUATION
the bash for the alleged exemption. Any violation of Section 7071.5 by any
a`�GO OUILEISSWTTCHESHXTURES
applicant for.persubjects the applicant to a civil penalty a n"mom than
Fermin O6
Cpp;; qq five hundredsowner of the pro NEW RESIDENTIAL RLECTR SQFT.
'9. ❑1,as owner of the property,or my employees with wage as their sole STOATS TYPE CONSTRUCTION
compensation,will do the work and the structure 6 not Intended or offered far
sale(54,0 7W4,Business and Porfesvlms Code:The Contra"ofs Lt..Law
$ docs not apply to an owner of property who builds or Improves I homer,and OCGGROUP RES.UNITS
who doessuchwork himself orthraugh hisawnemployees,provided that such
Improvements arc not Intended oroffered for sale.If,however,the building or TOTAL:
improvementhsoldwithinoneyearofcomplet n,theowner-bulderwglhave
t rden of proving that W did not build or improve for purpose ofsale.). QTy, PLUMBING PERMIT FEEpLOODZONE ppN
Lj L as owner of the Property,am exclusively contracting with licensed pFRh1fI ISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code:
The Contractor's License Taw don not apply to an owner of property who ALTER-DRAIN&VENT 0.+NN
Wilds or improves thereon,and who contracts for such p4ojer,with a
cc
pp]I((actor(•)licensed pursuant to the Contractor's License Law, gpCK p1AW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B 4c P C for this mason
QL2TSIDE FEE.
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORI4MAN COMPENSATION DECLARATION RECEBTN
❑I hereby affirm that I have a certificate of consent to self-Insure,ora I•TXTVRES PER TRMSCIi00L TAX Y N
ceAifirateof Workers Comperuatlan lnurance oracenghd copythereof(Sec, RECEIPT N
3800,Tab S N
PFA. INCA PARK FEE Y olity X GAREC=a
Com y GAS[A.SYSTG4-OVER4(EA) eUILDINGDIVEIONFF,ES
TJCertified Certified copy is herebytumCREASTIANDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE
Certified copy u 111-d with theecity inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlsse"lonneed na becompleted lftheperrtdt 6forone hundr-ddollars SEWER-SAMTARY-SIORM EA,200FT, Date Recel t#
(81 W)rtifyt a WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I cenot that o the performance ny co work so as to b this permit 6 Laved,
I shag not employ any person la any manner at n to become subject to the —
Workers Compensation laws o(Callfamh.Dam WATER SYSTEM/TREATING
z PAID
Z Applicant
NT:IL after making this
O NOUCETOAPPLICACertglcate of Fxemptbn,you NEW RESIDENTIAL PLMg._SQFT, Date Recei tN
should You
to the Workerompeatlon provBof the Labor TOTAL:
fA Code,you
must s Cnlov hwlth comply with such provisions or this permit shall be
LU > deemed revok-d. BUILDING FEE
d p CONSTRUCTION LENDING AGENCY MSEISMICFEEI hereby atnrm that there 6 a minmuctlon lending agency for the perform.Z ance ofthe work for which this permit 6 Wued(Sec.3097,Cr,,C,) TOTAL: Q
V Lender'sName ly H anisnadres QTY. MECHANICAL PERMIT FEEOWIcertify(hall have read thhappllotlonand state thatthe above InformationFEE
4 Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE- W relating to Wilding construction,and hereby authorize representatives of thiscity to enter upon the above-mentlomd property forWpe"les purposes, ALTER OR ADD TO MECH.(We)agree to save,Indemnify an d keep harmless the City of Cupertino RecCiptit
agaWt gabllitim,pcigmenb,costsand expense which may in anywayacarue AIR HANDLING UNIT(To To,000 CFM)
against said Cuy in consequence ofthe granting of this permit. SUBTOTAL:
AIRHANE)UNGUNTIT(OVER10,O00CFM) STRUCTION TAX
Signature of Apperant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumm building occupant store or handle hazardous HEATING UNIT(TO 100,00O BM
material as defined by the CupSWMoMu-kips]Code,Chapter 9,12,and the Date Recei tN
health and Safety Code,Sey16n 2.5532(a)7' HEATING UNIT(OVER 10"000 BTU) TOTAL:
❑Y. Na
Will theappllram or futum buil g occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit has rdous air con nb as ciefim:d by the Bay Area Air
Quality Management Dist BOILER-COMP OI IMP 100,OW BTU) , .. Qw� 1
Yo No L/*,
have read the haze ous materials requimments u nder Chapter 6.95 of BOILER-COMP(OVEt 100,000 BTU)
the Gl crnla Heal e,Se"lore SOS,25533 and 75536.1 C,SU
M
does oily have a tenant,that it is myNEW RESIDENTIAL MECH. SQ.FT. 1Spant requtr-marts which must be not
te panty. �,//`�/+�a5i W IIR�®Date A.�1-as
TOTAL: ISSUED BY:
OFFICE COPY