19706 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm:cct Identification 7 PERMIT NO.
Building XC . 19 7 0 6
2 a M
n`erss amt: phone: A IONSUBMIIIALDALE
(A�� T,S CITY OF CUPERTINO-BUILDING DIVISION —� b
C trrArtm'eNNamt" uaNaT'y
APPLICATION /PERMIT 2 ��
AT' BUILDING-ELECTRICALPLUMBING-MECFIAMCAL CATEGORY CONTROL M
m k
_ ELECTRIC PERMIT FEE BUILDING PERMIT INFO
7jPERMITISSUANCE El ❑ ElLICENSED CONTRACTOR DECLARATION
I hereby affirm that am licensed under provisions o(Chapter 9(commenc APPLIANCESRESIDENfIAL JOB DESCRIPTION
Ingwilh Sedion7000)of Dlvision3ofthe Bu sines ndProfessionsCode,andrey
license is in M tore and eft PANELS
LimnseC I 1 r1�ta In
Date Contras - LM IQ
"AMPS ,P( v -,`
2314 -
ARCHITECTS RATION OVER1000A.MPS SQ.FT.FLOOR AREA $/SQ.FT.
NO 2O I understand my pore atoll M used a public records.
Fe do E Licensed Professional SIGNS ELECTRICAL
<:WW OWNER-BUILDER DECLARATION
WI-n SPECIAL CIRCNT/MISC
p„ Ihirigrc ..(.nada,exempt from the Contractor's License Lay for city or
Q. (ouowing reason.(Semon 9mt5,Rosiness and Profemions Code:Any city or
OGH coup which re 1 permit tocoeetruct,alter,improve,demolbhlorre TEMP:METER OR POLE INST.
P county requires pe p pair
�e`acts anystmsurcpdortolb Issuance, rcquireatheappumnlforsuch ptrmlt to PAr&DEVICES
1 O fik a signed statement that he b Brensed pursuant to the)irovlamas of the
3 ec Contractor's License Law(Chepler 9(commencing with Section 7000)of Divi- VALUATION
G SWIMMING POOL FI.ECTRIC
O the ba The Buslnnsand Profcesio Code)orlation bexZilon 7ercfrom and
b fS<5 the basis for the alleged gecmtbea�Any violation of SMion 90115 by any OUTLETS-SWITCHES-RKTURFS
ape hundred
peani($50U)cv the applicant to a ii'vli pevlry o(na more thin
live hundred dtlkn(ASW). 1 Nai NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPECONSTRL'CTION
� G ❑I,asowner or the property,.,my employees with wages as their sole
compensation will clothe work andthesW sum b not intended or offered for
5 O sak(Sec.M0 Business sad Profession!Code:The Contraso?ks License law
does not a pply to an owner a propertywho Wilds?riiriproves thereon,and OCC.GROUI' RFS.IWITS
who docs such work himself ortheraugh his own Gmployees,provided ihal.0
Improvements are not intended oroffe'red fixt,61.If,howeveg thebulidingw , TOTAL:
Impmvement at sold within one ytarofcomipietiog lM owner-bbuWeruful M1iye
t"relen of proving that he did not build or Improve orrposeo le.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively aajt RI g wGM1 1 need PERMIT ISSUANCE
contracto s to rorolrus the project(Sce.7044.Rusinei a esstore Code: U!7
TM Ccu lnnor's License Law don nm apply man owner property who ALTER-DRAIN&VENT-WATER,
Wilds or Improves thereon, and who contracts for such ptojess with a z B O FEE SUMMARY
cQIltt ct (a)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
1_I I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. v SANITARY Y_ N_
Owner Date RFLFIIef N
WORKMAN COMPENSATION DECLARATION FD(gVRES PER TRAP SCI IDOL TAX Y_ N_
71 hereby affirm that I have a certificate of consent to self-insure,ora YA 0 9 RECEIPT N
certRimleofWorkers Compematton LsuranmoramAifiMmpylhemof(Sec. GAS EA.SYSTEM-1 WC.40IJTLET5
3N00,Lsb C.) z'0V PARK FFR Y_ N_
RECEIVE0
Policyp CAS EA.SYSTEM-OVER 4(FA)
Cnm any BUILDING DIVISION FOES
�Certlfed copy is hereby(umihed. GREASE/WDUSIRL WASE INTERCEPTOR
FEE
OCedlfied copy at filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WOR K ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XpFT. Date Recei tN
(TFIsse tion need nor be completed If the permit Is forom hundred dollars
(S10U)mrlow.) WATER HEATER W/VENT/F3-GCTR �eo ENERGY FEE Y_ N_
I certify that h the pon'. .m o(lhe work for which this paredi is issued,
I shell not empty any person In any manner w m to become subject to the WATER SYSIFAf/TREATINX;
Worker.Compensation laws of Callfornla. Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recei tt4
Z O NOTICE TO APPLICANT.If,after nuking that Certificate of Exemption,you
should become subject to he Woduns'Compvwtion proWkm of the Labor TOTAL:
W Code,you resat forthwith comply with such provisions orthb permit shall be BUILDING 'E
Wj deemed revoked.
CONSTRUCION LENDING AGENCY SEISMIC FEE
d O Ihereby afi n that there at acorulmction lendingagency forthe perform- 0 TOTAL:
O O � ELECTRIC FEE
7 Z an ofthe work for which this permit b bsued(Sec.3099,CIv.C.)
Iender.Name PLUMBING FEE _00
LL F Iendcr.Aad. QTY. MECHANICAL PERMIT FEE
O O 1ceni(yhatl have read lhbapplimtlonand statelhatthcabove information MECHANICAL FEE
W
ismrres.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r relating to building construction,and hereby authoram representatives ofthis
[_ N city to enter upon the abovt"menHoaed property for Inspection purposes. ALTERORADDTOMECH.
Z Date Reccipt#
(We)agree to d Indemnify an d keep harmles which
the City of ywaya tino crus
L) agai ,pd ,cowsand expenses whish nay In anywayaccrue AIR HANDLING UMT RO 10,000 CFM) SUBTOTAL: -0
agai ty uence of the granting or this permit.
o a AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
atureo pump Contractor I Da• lee EXHAIATHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haurdous HEATING UNIT(To 100,000 BTU) Date Recel tit
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
I ealth and Safety Cod,le SSelection 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: • o0
F1 yes
No
Will he applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS*k16ATE
which emit Mzardom air contaminants as defined by the Bay Arca Air �iN
Qjjality Management District? BOILER-COMP OFm OR 100,IX10 BTU)
Yea MNO
have mad the haza Mus materials rcqulrenenisunder Chapter h.95 of BOILER-COMP(OVER IOU,000BTU) ra0 jq1990
the Califomu Health&Safety Code,Sections 2550.5,8533 and 25534. 1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
respomibility,to notify the occupant of the requirements which must be met n a__ 0f rrIDMfID/�
prior to Issuance of a Certificate ofOompancy. W[�I
Owner r authorised agent Date I ISSUEDBA t WAUG44
TOTAL:
OFFICE COPY