19703 `APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT,PEN ONLY
Building Project Identification - PFRMITNO.
BuBding Address: `
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6 _ I�•�,AI?�C lVss� LSS-ZLI8 CITY OF CUPERTINO-BUILDING DIVISION
C°" ader.Name: J APPLICATION /PERMIT
( � � �KE,;; H I� S� 3 BUILD1NGFlECTRICAL PLUMBINGMECHAMCAL CATEGORY
CONTR
Architect/Engineer. 1^ Lie No-
!5
o: • (O
5TH C LLO - BU LDING PERMIT INFO
s GA��/ WA Q1Y ELECTRIC PERMIT FEE
Address: PERMITISSUANCE; fZ I PLUMB t
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(cummene- APPLIANCES-RESIDENTIAL jutiD R➢'1'ION
Ingwlth Srxdon7000)ot Dlvlslon3 ofthe Buslussand Profss.lonsCode,and my +
lirens'Isinful LfLmeandeffect. PANELS 7� FSC .'1
Llernse Ctss I, LICM Z sI
Date_Z_� �.Contract.r li
ARCHIIE SD CLARATION 701-1000 AMPS
�� ]understand my plans shall be sspub➢crecorda OVER1000AMPS SQ.Fr.FLOOR AREA f/SQ.FT.
�� Licensed Profnelorul SIGNSELECTRICAL' 18Z5- L)VIN
Q „ OWNER-BUILDER DECLARAV
rn - SI'ECALCIl2CUIT/M15C �� - G
F., Ihemby.ffl.that l am exempt from the ContrLIrthe
'ZO qQ�Q (o➢owing reason.(Sealers 7lli1S,Buelnca and Proor
F F'
county which requires permit tomrutruct,alt ,Imrepalr n'Mp•MEI'FR ORIOLE INSf.
anystmtlurepdortoltehaance,aLwr'quires 'armit to pplyEg DEVICES
O file aslgned statement that he b Ilreneed pu an ( t eContradorbLkc"••Lw(Chapter9(mermen DI
BOJto.3ofthe Buslnessand Professions Code)art hebexemptthe SWIMMING 1'ODL ELECTRIC VALUATION -
•77 the bash for the alleged exempll . Any of tl n of Be mi n 707Iteir
an /1
appllant(ora permilsubjects the pplka dull penalty ra1re
h OUTLETS—SWITCHES-FIXTURES 7
.five hundred delta.($SM. �1NEW RESIDENTIAL ELECTR SQ.FT. �4Z STORIES 742UCTION
C ❑1,as owner of the prope employees with a e a sole
5
compensation,will dotheB..ba e,an d esC da:Thr C int or to d(or .ALEp eik($ec,70N,Buelr�ess and lavCde:TheCoor a s Lllaw d�7—
j3$ doss not apply to an owner p pe
who builds or Imp 'thereon,and _ �\„ra�ara
0. who does such work himaelfo neigh his own employees,p Ided that such r�,y"Ih-�I/�YR
Improvement are not Intend orotfered for ule.I/,howeveq the Witing.r a 70Tp
ImprovemenW wldwlthln omyearotcomplelion,theowner-bullderwill have
tl6rden of proving that he did not build or improve for purpose ofuls). QTY, ' PLUMBING PERMIT FEE pgpNE
u I,as owner of the property,am exclusively contracting with licensed pp 1T L5SUANCE /
contractors to mnstruat the project(Sec.7044,Business and Professions Code: _
]'he C.ntmdorb License law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pIpjem with a ALTER-DRAIN B:VENT WATER(FA) _
cgnRadoIts'Bernard pursuant to the Contrader's License Law. FEE SUMMARY '.
LJ 7 em exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner - Data - DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
. -
WOR"AN COMPENSATION DECLARATION RECEIPT NFIXNRFS PER TRAP SCI TOOL FAX Y_ N_
'h.-
hereby affirm that I have a certificate of consent to eel(-Inwrc,or -
c kale ofWorken'Comperuatioalmumnmoramdlfledcopythertot(Sec. RECEB'TN
3800,1.b C) GAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y_ N—
Policy p GAS EA. — RECEIPTN
Com any RUILDIN DI VI SION FE ES
Certified copyb cmhyfiled
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCI'IECK FE tS' bA
Certified copy b filed with the dry inspection division. I
CERTIFICATE OF E)(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCERURANCE SEWER-SANITARY-STORM F.A.200Fr. Date RcCe1 I#
(Thio loss.) need net be completed If the permit b(.none hundred dollars
($100).rloss.)that
WATER HEATER W/VENT/ELLCTR ENERGYFEE Y N
Ironed that In employ
he any arson I any heworkmanner
for to b co permit ct to Ih, —
I shall not employ any.east.In any manner-at u to tiemma subject to the WATER SYSTEM/TREATING
Worken'Cempematlon Gws o/GII(omla.Date PAID .
O Z NOTICApplicaE RESIDENTIAL FLMS._SQ.FT. Date Rece1 t#
Z0 NOTICETOeB.bjettothe orkersfter kompensationing this ateolonsmpteLaborV6.i.2—
should Workers Compensation - TOTAL:
t/r
Code,you=at forthwith comply with such provisions or this permit shall be IRC I �50
W > deemed revoked. .. BUILDING
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hcrebyaffirmthat there Is a comtmctlon lendingagency forthe perform- ELECTRIC FEE 7 , 2
7 Z Lamice N mkfor which this permit b Issued(Sac.3097,C1v.C.) TOTAL:
C.) 2 L<nd'r's Name - 7• y PLUMBING FEE
LL - Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 7,
O W Iredlfythat l haveread this appllatlonand state that theabove Information is agreeto comply with all city and county ordinances and state laws PERMITISSUANCE 2'� FEES PAID:
} R mlamg io building mnstrudloryand Immbywthadze repoesconives.(this
I•' N city to enter upon the abinspection property for pection purposes. ALTER OR ADDTO MECH.
? (We)agree to save,indemnify an d keep harmless the City of Cu ped Ino Date Receipt#
L) against liabilities,)udgeonls,mats a od expenses wh lch may In any way accrue AIR ILA NDLING UNIT DO 10,000 CFM) - SUBTOTAL,
Z::�g uld City m our.equenceofthegr ting thlspermlt. -
2 on ZR HANDLING UNIT(OVER IB,BBBcmd) CONSTRUCTION TAX It�4'1•
gna of Applicant/Contractor t Date/ �= �FXRAUST HOOD(W/DUCT). CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUBE
Will the appilant or(umrebuilding occupant stores handle hazardous }(EATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date - Recel t#
Health and SafetyCeder..Sec11on 25532(a)? HEATING UNIT(OVER 10,000 BTU) TOTAL:/
j� Yee - u o
111 the appliant0PtuNre building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE/
which croft haxard°us air cootamiwnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTI()
4 Ycs N No ^
have reaE the hazy our nutcrials requirements under Chapter6.95 of BOILER-COMP(OVER100,000 BN)
the California Health k Safety Code,Sections 25505,25533 and 25534. 1
understand that if the building does net currently have a tenant,that it b my NFWRESIDENTIALMECH. SQ.Fr.'
nsponsibllity to notify the occupant of the requirements which must be crierQ0 '
pdartolssuanceofaCedlflateof Oc pancy.
Owner or authorized agent Date 4S10 2
TOTAL: ,SYZ2 ISSUED BY:
OFFICE COPY