19852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prded Identification PEItMITNO.
B°Bdina A""_ _ 19852
'14' ��st . Pi'✓LQ�
- Q'T'.rvame-- N Phone A A A
CITY OF CUPERTINO-BUILDING DIVISION
Conuadors Name: p Lk.No: APPLICATION /PERMIT D
O CLUM c—, BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROLN
Archlt /Engineer. Llc.No:
O QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
�ddrcsa: .2 t% T5& uc/K l/ Ens!' g y PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
thereby affirmthat lam homaed under providonsofChapler9(wmmcru APPLIANCES-RESIDENTIAL JOB DESC ON
ingwlthSmionID )of Dl sion3ofthe Bugm and Pmfe onsCode,andm
license Is In full force and effect. `; PANELS
License Class � LIC.N 2 ti-C>- D 3 ,�/
Date Cantndar M6. UP TO 200 AMPS 1000 A.MI9 1"L U M b'!eV(3, e / p 1_a>'�
ARCHITECTS D CLARATION
7 I understand My plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA
COZ� Licensed Professional SIGNS ELECTRICAL
<w� OWNER-BUILDER DECLARATION i, Fn (firtSPECIAL CIRCUI /M
s., > thereby anthatlam exempt froContractor's mthe Contracre License Lawlor the
F Q E- following reason.(Section 7071.5,Business and Profealons Code:Any dty or TEMP.METER 'INST.
countywhlch requires a permit to construct,alter,improve,demolish,oreepair
qq a anystsucturc priorto its issuance,atao requirestheapplicant forsuch permit to POWER DEVI
6' V file a signed statement that he Is licensed pursuant to the provisions of the
�aContractor's LicemeLaw(Chapter 9(commencingwith Section7M)ofDist- SWIMMING POCVFrF VALUATION
O< slon3o(the Businessand PmfealonsCde)orthat he 6 exem therefromand
=F yl^t the basis for the alleged exemption. Any violation of Section 7M1.5 by any OUTLE'ISSWITC ES
<n
applicant fora permit subjects the applicant to a civil penalty of not more than
EE4E��11 five hundred dollars($.AO. NEWRISIDENETIALE16CTR_SOFT. STORIES TYPE CONSTRUCTION
es as their sale —
El compenas sation,wrof the ill do the work end t�tr�cttom 6 not Intenees with d dor offered for
5 ❑ sale(Sec 7044 Business and PMealons Code:The Contactors License Law
$� does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
whoilmssuchwork himself orthrough hisownemployees,provided that such
Improvements are not intendedorofferd forsale.IL however the bullding or TOTAL:
improvement usold withinoneyearofcompletiogthew er-WBderwill have
t�c�+edenof pmvingtlut he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE IB.00D ZONE APN
L�4 as owner of the property,am exclusively mntractlng with licensed PERMIT ISSUANCE
cantnctmn to construct the project(Sec.7044 Business and Profession Code: j J
the Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such piojects with a ALTER-DRAIN&VENT-WATER(EA)
ry➢lfador(s)Bcamod pun tsm to the Contadors Limine Law. FEE SUMMARY
u 1 am exempt under Sec. B&P C for this lesson BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
v ,Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
s WORKMANCOMPENSATIONDECIARATION FO(711ftFS PER TRAP2Z SCHOOL TAX Y �NN
❑1 hemby a(llrm that I have a cartifiate of consent to self-insure,ora RE EIPT N
mrtlflcate of Workersmp
Coereauce
on lnsunnm ora rtiffed cagy thimof(Sec.
GAS F.A.SYSTEM-1[NGdOUTLETS PARK FEE Y_ N
y 3800,Lab CJ — RECEIPT
Pol try Y S GAEA.SYSTEM-0VER d(FA)
Com any BUILDING DIVISION FEES
�Cenl(Ied copy is;hereby famished. GREASE/INDUSRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MET. Dat¢ Remi t#
(rhlssmion need not be compidd Bthe permit b for ata hundred dollars
(5100)or Jr.) WATFRHFATrRW/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance of thework for which this permit Is Issued,
I shall not employ any person in any manner m as to became subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of Callforma.Date I PAID
Z Z NOTCETO APPLICANT.If,after mal ngthis Certiflate of Exemption,you liem NEW RESIDENTIAL PCMB. SQFT. Date Remi t#
0 should beameasubjm to the Workers Compensation provisions ofthe Labor TOTAL:
N Code,you at forthwith comply withsuch provisloncorthis permit shall be BUILDIN
GFEE
LI > deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. O (hereby affirm that there Is a construction lending agency for the perform- ELECTRIC FEE
M Z anceofthe work larwhkhthLs permit Is Lssted(Sec.3097,Cio.C.) TOTAL:
L) O Lender',Name PLUMBING FEE -96-90
LL I— I.edersnddress �p.ata QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icartifythatt havereadthbappliatlonad statethattheaboveinformation
O W iscorrect.I agree to comply with all city and cauntyordinanas and gate laws PERMIT ISSUANCE FEES PAID:
IL relating to building construction,and hereby authortve representativesofthis
F V) cttyto enterupon the abovo-mentlomd property for Inspection purposes. ALTER OR ADD TO MECH.
_ Date Receipt#
(We)agree to adgresi indemnify an d keep harmless hick the City any ss.y.ecrue
.ecruepert into MR HM,IDLING UNIT(TO 10,000 CFM)
U against liabilities,rydgmenb,cost...d expenxs which may In anywayaccme SUBTOTAL:
agabat,ald Cityin ceofthe grantor mpermit. CONSTRUCTION TAX
n en B_ A� e' AIR IiANDLING UNIT(OVER IO,IXIOCFM)
Signatureoff Applicant/Comraa-ctor �•J'Palo EXHAUSTITOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATINGUNIT(T0100,0001IIlI) Date Recel t#
material as defind by the Cupertino Municipal Code,Chapter 9.1 7,and the cry
I lcallh and Safety CdeSSeaion 75532(a)7 HEATING UNIT(OVER l 00,000 BTU) TOTAL: �C'✓
nYes No
Will the a pplicant or uta re building occupant use equ 1pmenl or devices VFNIILATION FAN(SINGLE RESID) ISSUAI�C\TB,DATE
mi
-, which et havedoos air contaminants as defind by the Bay Area All �
BOILER-COMP OF IF OR 100,"8 TU) 1
Quality Mamgemcnt Dlsldd7 � V
4Yes 1RNo y,J7
have read the hacaWous materials requirements under Chapter 05 of BOILER-COMP(OVPR 100,000 BTU) 't 4
the California Health&Safety Cde,Sections 75505,25D3 and 75534.1 at Y
understand that if the building does not asrrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.ET.
easporsibilityto notify the occupant of the requirements which must be mat
primrtolssuance aaCe If ateof Occupancy.
1 Ow^ rauthorfeadagerilldJ S Date TOTAL: ISSUED
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OFFICE COPY