19662 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
PBuilding Pm+ed Identification - PERMIT NO.
12
'od655PNTERS HATCI+ 19662
Z7.7717._ Phone: A
74 N
r F R 1=N C CITY OF CUPERTINOQBUILDING DIVISION4 Q
Contract.. N"ne' / r LTe No: APPLICATION /PERMIT
^ —
/_ G N?�SGN/Z 6rI SUMDINCELECTRICAIPLUMSING-MECHAMCAL CATEGORY CONTROL M
Architect/Englover.. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 1:1 11 11LICENSED CONTRACTOR'S DECLARATION
IV I hereby affirm that 1 am Ilemsed under pmvislons of Chapter 9(mmmmc- APPLIANCES-RESIDENTIAL . JOB DESCRIPTIONIngwllh Section 7000)o(DWlelon3oflhe Business and Professlons6cle,and my
license le In full force and effect. _ PANELS
Licensen ClaavC-za Llctl �_ � _
Date rC� Contractor_ _ yt h e
Aep
ARCHITECT'S DECLARATION 201-1000 AMPS
p❑�a0 O I understand my plsm eha8 be used as public records. OVER 1000 AMPS LSA`.[YR A� $ .FT.
F Iy 1 IMP
a. Licensed ProfessiorO SIGNSELECTRICAL C
6 OWNER-BUILDER exempt from
DECLARATION SPECIALCIRCIIIT/MISC
Ihercbyaffirm that 7amexempt(romthe Contractors License Law for the
p following reason.(Section 7031.5,Business and Professions Code:Ancit or `
Ff'ty cmntywhichmquimsaperndttommtmc,alter,4npmve,dem Ush,ormpalr ThMP' METFR OR TOLE INST. a (fl
3 anystmcNrc priortolts baance,also requlreslhe applicant for such permit to
r�E Die a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3µOr Contractors Licerse law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING POOL ELECTRIC
sloRlofthe Buslneasand Prafesdom Code)orthathebettmptthemfmmand VALUATION .
the basis for the alleged exemption. Any violation of Section 7031.5 by any T2
<� applicant fora permit subjectstheapplicant to a civil penalty of not morethan OUII-ETSSWITCH6FIXTIJRFS / / OO (�
five hundred dollars 1$5 . NEW RESIDENTIAL ELECTR FT. l0
❑1,as owner of the property,or my employees with wages as their sole _SQ.Fr, TORUS TYPE CONSTRUCTION
compensation,will dotal work,and thestmdure Is not Intended or offered for
O
Date(Sm.7044,Business and Prolemioro Code:The Contractors License Law
$ does not apply to an owner of property who builds or improves thereon and OCC,CROUP RES INKS
who docsauch work himself orthrough hi......ployees,provided that such
Improvements arc not letended oroffered foreals.11,however,lhebuilding or TOTAL:
Improvement ls sold within oneyearo(complelion,the owner-W llderwiil have
the burden of proving that he did out build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
[:f Las net of the property,no,exclusively contracting with licensed PERMIT ISSUANCEcontactors to construct the project(Sm(S70K Business and Professions Code:
The Contactors License law does not apply to an owner of property who ALS-DRAIN A VFM-WATER(EA)
Wilds or Improves thereon, and who moment for such p(ujecta with a FEE SUMMARY
r%420orts)licensed pursuant to the Conteache.License Law. BACK FLOW PROTECT.DEVICE
L j I am exempt under Sec B A P C for this reason
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
• Date
WORKMAN COMPENSATION DECLARATION RFOEB'T tl
FD(TURES PER.TRAP SCHOOLTAX Y N
❑I hereby a(Rrm that 1 have o imumn of consent d pytherso ora RECEPr X
380.ft0,1 b of Workers Compematlonfrsumnm ora certifkd copythereof(Sm. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
policy
lab C.)
Poiiry p DING DI X
Cam an GAS EA.SYSTFAI-0VER4(FA)
Y BUILDING DIVISION FEES
• Certified copy ls hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANGHEGK FEE
Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEW FR-SANITARY-
(rhissectionneed not becompietet lfthepermit bforone hundred dollars STORM EA.200FT• Dale Reeei t#
($100)orlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icenify that In the performance ofthe work forwhkh this permitb heed, —
I shall not employ any person In any manner so as to become subject to the WATERSYSIFM/TREATING
WorkeeCComcns
pation Lawsof Ca Bfomia.Date PAID
Z Z Applicant
Z oNOTICETO APPLICANT:IL after making this Certificate of Exemption,you NEWRESIDEN77ALPLMB.. SQFE Date Recet t#
should become..bpd to the Workers-Compe...tlon provisions of the Labor TOTAL:
~ N Code,you most forthwith comply,wltheuch provisions orthla permit shall be -BUILDING W y deemed revoked.
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1herebyafRrmthal them ls a corotmction lsnding agenry(or the perform ELECTRIC FEE
Z ance of the work!or which this permit In bated(Sec.30W,Civ.C.) TOTAL:
U O Lender.Name PLUMBING FEE
LL Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W T certBythat l have read thlsapplicatlonand slatethattheabove Information
1 is l agreeto comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
). W relating to building construction,and hereby authorize representatives ofthls
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against it billtie pdgmenta,cost d expenwswhkh may In anyway accrue AIR HANDLING UNIT(To 10,000 CIM) SUBTOTAL:
.gal aid Ci Inc race of he canting of this pemdt.
AIR HANDLINGUNIT(OVER 10000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date allAusr HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha rad Is hazardous HEATING UNIT(TO 100,00)RTU) Date RCC01 t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
flea lth a nd Safety Ccdv�, ctIoa 25932(a)? HEATING UNIT(OVER 100,000 BTI) TOTAL: . 3 e
RYes (6 No
ill the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air ronfaMmnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTI) p1 q 83A.
4 Yes jNo U`CNRS%
have readthehara sea materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 RTU)
the Ca a mia Health k Safety Code,Sm lora 25505,25533 and 25534.1 1391understand that if the building does not mr..tly have a tenant.that it is my NEWRFSIDENTIALMECH. SQ.FT.
occupant �• 1 J
resporsibll Ity to notify the occupant of the retirements which roust be met
prior to Issuance o(a CertlRcale of Ocmpanry. r�4"sneAlpfJ(s'b
Gtr has
Owncror authorized agent
Date �IUE tivCL
70TAL:
OFFICE COPY