19638 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
Building,A-0rem: a _ 1660 19638
ncr. ante: Phone ArA A
CITY OF CUPERTINCLBUILDING DIVISION /�
cont" °' Lic No: APPLICATION /PERMIT L �O
Architect/Eng{nee Lk.No: BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
QTYELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PERtATISSUANCE ❑ ❑
LICENSED CONTRACTOR'S under rDECLARATION
IhthSedJflrnthat7")o Divtans konsMueBuMnevislonsof Chapter9(rommmy APPLIANCESRESfDENT1AL X ASK
ingwi )OB DESCRIPTION
nameh inion foresafddfoon3 ofthe Buslnessand PmfesslonaCodeacid my
Lld. is in s tura and c,I PnnrFvq
License Chss _{ Cont ��
Date Contractor
ARCHITECPS DECLARATION 201-1WOAMPS
q�+,�0 X, I understand my plans shall be used as public records. OVERIODOAMPS SQ.FT.FLOOR AREA .$/SQ.FT.
it Z(2 Licensed PMesslovl SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SI'ECIALCIRCUIT/M1SC
I herebyefirrnthat l am exempt fromthe Contractors Llanse law for the
following reaaon.(Section 70315,Business and Professions Code:Any city or TEMP.MErER ORI'Oi,E INST.
rr v�q' countywhichrequlmsapermlttocorutmnalwer prove,demo h,ormpalr
fl,,<. anystmu mptl rtollsissuamc alsorequimstheappllcantforsuchper tto
O U file a signed statement that he Is licensed pursuant to the provision of the POWER DEVICES
w Contractor's License Law(Chapter 9(comar nemg with Section 7000)of Diva- gWIy1,�gNG POOL ELECTRIC 0� sion 3 ofthe Business and Profsadov Code)orthe heisexempt therelromand VAIAATION
.x-11 the basis for the alleged exemption. Any violation of Stolon 7(01.5 by any
applicant far.permit subjecbstheappinam to a civil penalty of net more than OUTLETSSWITCHESHXURES
e, live hundred dollars($.900). Q�Q
^� I as owner of the property, NEW RESIDENTIAL ELECTR Fr.
❑, p ork,a or my employees with wages r thele sole `'Q S RUES TYPE CONSTRUCTION
C <
compensation Business work, lmthe strudo:TheCure Is intended orofferedL w
$�O sale(Sec.7014,Business and Professions Code:The Contractor's License Law
does not apply to an owner of property who builds or improves thereon,andOCG CROUP RB UNITS
whodoessuchwork himself or#rough hisownemploye et,provided that such
Improvements are not Intended oroffered(orsals.If,however,the building or TOTAL:
improvement bsold w thinoneyearorcompletiogtheowner-bu0derwill have
"ril*Nen ofpreving Nat he did not build orimprove forpurpossofses.). QTY, PLUMBING PERMIT FFLODU 7DNE APNEE
u
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSLfANCE
contractorsto construct the proper(See,7044,Busmcns aofe
nd PrssionsCode: s t70
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN kVENT-
Wilds or Improves thereon,and who contracts !or such pSojs a with a WATER(FA)
a ador(a)Oanaed pumoset to the Contrador.Llave Law. BACK ITAWPRO77Lr.DEVICE �CJtJ FEE SUMMARY
I am exempt under Sec. B k P C for this reason
Owner Dee DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby aflims that I have a certificate of consent to self-insure,or a FIXTURES PER TRAP SCITOOL TAX Y N
arti(IcateofWorkers'Compevatlonlnsumnaaaartifkd ropythereof(Sec. RECFL'rN
380,Lab C.) GAS EA.SYSTEM-1 ING40UTT.= PARK FEE Y N
Policy Y RECEIxr M
Cam any [ GAS EA.SVSDM-OVER4(EA) BUIL DING DI VISION FEES
❑pCertified ropy Is hereby tum a iax.city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECR FEE
,L�(i Certified copy Is filed with the city Inspection division.
']� CERTIFICATE OF EMiMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE -
(Thisaenion need not becompleted ifthe pcmNt lsforovhmdred dollars SEWFIL-SANITARY-STORM EA,2WFT. Date Recei t#
31 W)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I artif employ
o any Person
any he work so as tobeco pemdjectt is to he _
I shall not employ any person In any mnia Dat u to become subject to the WATER SYSTEM/TRFATING
woplicant mpcnsatlon laws of California Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:If,after nuking that Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQ}r. Date Recei tN
should become subject to the Workers'Compensation prevhlonsof the Labor TOTAL:
~ N Code,you must forthwith comply with such provisions orthis permit shall be Op
W > deemed revoke .
W dBUILDING FEE
11 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that thea a a ermtvnlon lending agency forties perform
7Z angof er's Na work for whkhthuperMtbbsued(Sec.3097,Civ.G) TorAL: ELECTRIC FEE
U O der'.Name
PLUMBING FEE /
IL I— Imcice.Addret. QTY. MECHANICAL PERMIT FEE
O W IaNfythat l have mad this applicationand state that theabove information MECI-IANICAL FEE
1 Is correct.I agrato comply with all city and county ordinances and state laws PERMIT FEES PAID:
} W relining to bulidingconswction,and hereby authodve representatives ofthis n7 /w
Z city to enter upon the above.me Honed property for inspection purposes. ALTER OR ADD TO MECH. •S
— (We)agree to save,Indemnify an d kee harmless the City of Cupertino Date ReoeipHl
agaivtllabilltma,' Rt¢nb,astsand ex 07 which nuy In anywayaccrue AIR HANDLING UMT(1'010,000 CFA4) SUBTOTAL:
agaanstsaid a rc n quen �fthe antingofthi.pennit.
��/j)D AIRHANDLINGUMT(OVERIQDJOCFM) CONSTRUCTION TAX
Sig ua (,ppRcant/ cor Da / '/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA OUS MATERIALS DISCLOSURE
Will the appgcanto inure bu0ding oavpaat store or handle havrdous HEATING UNIT(TO 100,000B
material as defined by the Cupertino MI Pal Cods,Chapter 9.12,and the M Date ReCeI tN
❑
HM Yes and Safety Code SectNo ion 25532(a)7 HFATING UNIT(OVER 100000 BTU)
_ I] TOTAL:
Willemit
applkantorr contamldinginants
occupantuse the Bay Area Ai vices VENU[ATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardoua air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HPOR 100,000 BTU) PAID Yes o
havemadthehaz-yONmalenalsaquaremcntsunder Chapter 6.93 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25534.1 //,� [T•�'7
mdersmnd that if the building does not currently have a tenant.that it is my NEW RESIDENTIAL MECH. SQ.I.7. FEB ldg �JJU
rapr to Issue,
noti ocapa je(the reyuircmenis whkh must be met
prior to lssuan 0. aF
'��� Clhr fa ^ea�gT}jRl1
lir or oriy Date
IOTAL: ISSUED BY:
OFFICE COPY