24112 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NVQ/7
Build ing Add oras: (,a 4 1 1 2
10918 PALO VISTA ROAO, CUPEF'TIKJ 0
nerdName: one:
R06ER Aa STEN 2s3z7_40 CITY OF CUPERTINO-BUILDING DIVISION
Contactor'sNanne: Lie.No: APPLICATION /PERMIT I� Z
BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY C QL
Architect/Engineer. Lie No: v
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I Mreecl.tion affirm 000M iNelonsedhe er Busi essimnaofChapter asi...9(wmmenc APPLIANCESRESIDENTIAL /rra � BDGSCRB•DON
fngwhh Sec Jon force an Dlveet. ofthe Buslnessand Pro(ealonaCode,andm r l o az>
Licens fiowsaKlass form and effect. , PANELS w �)a QJ
LicenseClass Cont =44It/✓`V'
Date GHITEC7r 201-1000 AMPS '{�'+
ARCHITECTS DECLARATION
qq��uv�2 (understand my plansaMBM used as pubec eecmdd OVER 1000 ANTI'S SQ.FT.FLOOR AREA 5/BQw.FT.
k uLicensed Prnfesshmal SICNSELECTRICAL I ire C
<Q OWNER-BUILDER DECLARATION VV �T CJ
N`• cut SPECIALCUtCUIT/MISE
9 owing reason.
tMion 702emptfro es he sad Profdor'.Wrense law fort he —_ � �M Q/sa � QI
oo following reason.(Secilon 7¢)ts,Boniness and Pcofesslons code:Any city or
07F'u9 county which requlresa permit tocombud,alter,Improve,damollsh,or repair TEMP.METER OR POLE INST.
any structure prior to its Issuance,also requlresthe applicant for such permit to POWER DEVICES
0. file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License LaW(Cha(Chapter with OaG S SWIMMING POOL ELECTRIC
EO sbn3os he Business and exemption.Code)violation
n of exempt thercfromany ' � VALUATION
a � the basis for the alleged exem)alon.eAny vlolatlon o!Section 7031.5 by any O UILETSSWITC[iCSFIXTURES Q—`]+}/al(�—X\�
appllant for a permit subjects the applicant tea civil penalty of not more than
five hundred della.($500. R
I ..owner of the 1 with wages as their sole NEW RESIDENTIAL ELECIR SQ.FT. 5�70 ES 7Y1 �,pI�S1RUCTION
compensation,will do the work,and.. ❑, property,or he structure Is not intended or offered for employees g O V V��p7
$ O die(not app4,Bualnowner
andf property
Codeho Wilds Compreves thereon law
3S domnmepplytoakhl nlorthmgy sownedsorimpmvndecitln,andUIVuFR
whodoements am
ow ale.IL yms,providedthatwch 1 B
Improvements am not Intended proffered(orale.I(,howeveq thebulltling m T
improve ntbwldwthinomc arofcompletion,tMo ner-buiWerwillbve AM
t
an
proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ntr o.to construct the project(See.704y Business and Professions Code:
TM Ca ctarb License Law does not apply to an owner.f property who
ALTER-DRAW&VENT-WATER(E.0 �-
build.or mproves thereon, and who contracts for such ptojacts with a
ctt.[+Orals)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LI i am exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE
Q-ITSI DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N�
'honer Dau RECFR'T N
WORKMAN COMPF SATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
E31 hereby all]=that I have a certhfiate of consent to self-Insure,or a RECEIPT X
certificate ofWorkers'Compersatron Insurance or a certified copy thereof(See. CAS PA.SYSTEM-1 WC.d OOILETS PARK FEE Y_ N
Policy
lab CJ - RECEIPT X
ohcyY CAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION ECS
cram any
[]CerBOed copy is herebyfurnished.the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANC.HEC S too
Certified copy ls(heed with tM.ety Iropectlon division.. /
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAI B.co
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200FT. he RCCCI
(This section need not be completed if the permit Is for one hundred dollars
($1W)orlem.) WATER HEATER W/VENT/ELECTR ENE FEE
I certify that In the performance of the work forwhlch this permit is towed, (-� 60
I shall not employ any person in any manner so as to become subject to the WATER SYSITM/TREATING
WorketV Compensation Laws of California.Date PAID
Z Z N077CE TO APPLICANT-.ILaher making this Certiticateof Exemlicant ption,you NEW RESIDENTIAL PLMB. SQ.FT. Date nee
O should become subject to the Workers'Compensation provisions of the Labor TOTAL:
H N Code,you oast forthwith complywithsuch provisionsorlils permit shallbe
i j deemed revoked. BUILDING FEE
W - CONSTRUCTION LENDING AGENCY SEISMIC
(L I hereby afflrmthatthere eacomtruction lendingagency forthe perform- ELECTRIC FEE
0 Z ante oftheworkforwhlch this permit is headed(Sec.3097,CN.C.)
00 I,endee.Norm PLUMBING FEE
I- Mndera Address QTY. MECHANICAL PERMIT FEE
O L)I cortdythat l have read thbappllatlon and statethattMabove information MECHANICAL PEE
bcorred.I agrcetocomplywlthallcity and countyordinancesand state laws PERMIT ISSUANCE FEES PAID:
>_ S Mrelating to building construction,and hercbb
yauthorlacmpresentativesofth
F.• Z city to enter upon the above-mentiotu'd property for inspection purposes. ALTER OR ADDTO MECH. DRIC Receipt#
V _ (We)agree to ave,indemnify an d keep harmless the City of Cu pedlno MR HANDLING UNIT(TO 10,000 CFM)
agaWtlinbNtln,' gmenb,costs an sea which Nylan wayacer" SUBTOTAL:
agaI old Cit `Je'uenceof x ti ofth`Is TAXYdS.�.. e4AIR HANDLING[JNIT(OVER IO,000CFM) CONSTRUCTIO UBTSI ofham/Contract. Date EXHAUST FIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC
Will the applicant or future building occupant store.,handlehaeardous HEATING UNIT OD 100,000 BTU) Date Re el t#
terlal as defined by the Cupertino Municipal Code,Chapter 9.12 and the
11th and Safely Code Section 25532(a)7 HEATING UNIT 100,000 BTU) T T
r-1Yes,llthe In NO
Wapplicant occo
ant or future pam VENTILATION FAN REBID)use equipment or ISSUANCE DATE '
which emit hazardous air contamim nb as defined by the Bay Arca Air
Qua lity Ma agement Distdd7 BOILER-COMP p1M OR 100,000 RTU) RlP�� pp B��'1
❑Yes Q No P A I N
OIhrc.adthehazar7i pusmlerl4lmqul,mel,unlerChaple,1,95oI BOILER-COMP(OVER 100,000 BN)
the California Health&Safety Code,Sections 75505,25533 and 25534. 1
understand that lithe building docs not currently have a tenant,that it is my NEW'RESIDEN77AL M[iCFi. SQ.FT. MAR
X� 9� ����
rapmeibillty to notify the occupant of the requirements which must be met MAR C�D
prim to Issuance of a aAifk to of Occupancy.
(Tuner or authodud agent Date — ISg(n5p BY.
T '
OFFICE COPY