20120 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: -
I I13 CoA vias Pc 20120
neer. ante. me:
�� Q I�TQ L 25L-813(. CITY OF CUPERTINO-BUILDING DIVISION
can —1
�attar.Name: ue."°: APPLICATION I PERMIT
Arehltect/Engineer. Lie No: BUILDINGFLDCTRICAL-PLUMBINC MWJH NICAL CATEGORY 'CONTROL N
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrces: - PERMITISSUANCE 2s� E:1 �jj ❑
LICENSED CONTRACTOR'S DECLARATION LTJ
I herebyaffrm that l am licensed under provision o(Chapter 9(oammenc APPLIANCES-RESIDENTIAL JOB DESCRIPTIONingwithSMton7(XIO)of DiWsion3oflhe Bustnemand Pro/emionsCode,and
try LI.. le In full force and dtM. PANELS r4, ['T�^`�
LlmneeChm LILN j6D C) 1I
Date Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
q�7 I understand my plane shall be used as public records. - OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
L� Licensed Profemtorul SIGNSELECTRICAL
<.4 OWNER-BUILDER DECLARATION
t`n a SPECIALCItCUIT/MISC
Ihereby affirm that l amexempt from the Contractor's License Law for the
pp / nwingreason.(Semon7 tW Businessand Pra(emCode:Anycity
021: TEMP.METER ORIOLE INST. - '
�� countywhim rarybaapemdtbcomtruq alter,Improve,
vedemolkh,orrepair ir
y aU any structure prior to its issuance,also requires the applicant for such permit to OWER DEVICES
rG file a signed statement that he is licensed puesuant to the proviskne of the
3p� Contractors License Law(Chapter9(mmmenclng with Section 7000)of Divl- SWIMMING POOL ELECTRIC
� 5 sion3oftheBuskemand Pr.f.is.Code).,thatheisemmptthemfmmend VALUATION
the bask for the alleged exemption. Any violation of Section 703LS by any OUTLETSSWITCHESFIXTURES
a0 applicant for a permit subjectsthe applicant to a dell penalty of not more than
IT ve ondrcd dolkm($.500).
ISI' NEW RE4DEN'MLELECTRSQ}T. STOWES TYPE CONSTRUCTION
I,as owner of the property,or my employees with wages as their sok
< c m enaatice,will doth,work,andthe structure k norintended or offeredfor e1
O ink(Sec.7054,Business and Profemtom Code:The Contrectors Llceme law 4
�$ don not apply to an owner of property,who Wilda or improves thereon,and OCC.GROUP RFS.UNITS
who doetsuchworkhk:selfortheaugh hieownemployees,provided thatsuch ^*
improvemenkmnotktendedorofferedfwmle,l(hawevegthebuildingor TOTAL: s
improvement b rld withinoneyearafeemplellon,theowner-Wtlderwill have
Of-turdenofpmving that he did not build ortreprove(wpurpom ofeele.). QTY, PLUMBING PERMIT FEE
LI L as owner of the property, FLOOD TONE APN
p peject em exclusively Business
contracting with licensed PERMIT ISSUANCE'
contractors eContict mmWd the w do (Sec,appstoan and of prop rt Code: tel/
The Contractors License Law don oho co ttr to an owner a(Property who ALTER-DRAIN&VENT-WATER(RA)
Wilda or Improve thereon,and who contracts for such p(ojem with a FEE SUMMARY
�yBT orfs)Banned pursuant to the Contractor's License Law,
• O1w_J I rx empt Mer c. 10 1 B &P C r this m
BACK FLOW PROTECT.DEVICE
G cm
DRAINS FLOOR ROOF,AREA,C
ONI). SANITARY Y N
ne D t RFGmPT
WORRMN/ ECAA
N
FEKTURESPERTRAP SCI{OOL TAX Y N
❑ ercby affirm that I have a certi of consent totneure,ore RECEIPT N
cem0ate of Worken'ComperuaHonlmumnnce w a ceHlfkd mpypylhereof l5ec.
3800,1.6C.) CAS PA.SYSTEM-1 WC.40UTLEIS �` PARK FEE Y' N_
Policy N RECEIPT N
GAS EA.SYSTEM-OVEAJ GR 4(E
Com ny BUILDINDIVI$IDN FEES
CCerttfiedcopy k hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHGCK FEE
❑CCHHted copy k filed'Mth the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.WENT. Recei t#
(Thistectisn need not W camplded lithe permit kfor one hundred dollars
(5100)orleaa.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I mrtifythat In the performenceaf the weak forwhich this perreft is Issued,
I shall new employ any Ernesto In any manner so as to become subject to the WATER SYSTFA7/IREATINO
Workem'Compensation laws of California.Date PAID
O Z, Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Races t#
Z O NOTICEco esubjet tothe,after Workerking s'
Compensation Cerin pro o(ons oft eLyou
H s ode,yo =ata rthwit the Worken' proven provisions permit
s Labbe TOTAL:
N darned remustforlhwilh comply with each provkiom or this permit shall be
� � deemed revoked. BUILDINCP •
.aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affimethet there h a mmtructlon lending agency for the perform ELECTRIC FEE
Z ansa of the work for which this permit Is Issued(Sec.3097,CIV.C.) TOTAL (� s
02 Lenders Name PLUMBING FEE
LL H Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imnlfythrtl havereadthkappBmtlon and statethatthe above Information
D. hcorrect.(agree tocoeply withaV cityaod county ordinances and state laws PERMIT ISSUANCE FEES PAID: .
). relating to building comtrucfIon,and hereby authorlu representatives ofthk
~ y cit to entero n the abova-mentioned propertyfwW Ion ALTER OR AUDIO MECH.
? y(We)agrees save,indemnify an d eeharmless theity of Cupertino Date Receipt#
V against liabilities judgments,caste and expense.which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
against cold City In mnsaquarme at the grant leg of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant°rfuture Wilding occupant store or handle hazardaus HEATING UMT(TO 100,000 BTU) Date ReceI t#
.tamales defined by the Cupertino Municipal Code,Chapter 9.17,and the
Fkalth and Safety Coder.-Srection 25532(a)7 HEATING UNIT(OVER 100,(X10 BTU) TOTAL:
❑Yrs u No
WVlthe applicant or/umre Wilding occupant use equipment ordevicee VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardous ah contamimne as defined by the Bay Area Air j
Quality Management District? BOILER-COMPQItPDR100,00011TN PAM .
❑Ye. ❑No WII✓J
� Ihavc read thehazallous materials requiremenk under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) APR the Califomk Health&SitfatyCode,Section
s25505,25533 and 25534. 1 1 gLj
ttL jg
understand that tithe building does not currently have a tenant,that it is y NEW RESIDENTIAL MEIN. SQTT. 1` J7
responsibility to not ify the occupant of the requtmeon/s which must be met . h�
prior to Issuance at a Certificate of Occupancy.
Owner or authorised agent ' Data
TOTAL: ISSUED BY:
I
OFFICE COPY