19834 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY V
Building Pm�xd Identification PERMIT NO.
Building Address: 19834
Lrwrer. ante: hone: � A
ZSS-Ii3T$ CITY OFCUPERTINOBUILDINGDIVISION
CAIN.dar'eNanta: seat.N°: APPLICATION /PERMIT
Llc.Na:
BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATT-GORY CONTROL
Architect/Engineer. J a C
.QW ELECTRIC PERMIT "FEE BUILDING PERMIT INFO
Addresa
PBRhRTISSUANCE 1:1 ❑ 0
LICENSED CONTRACTOR'S DECLARATION
Ihereby a film that lam licensed under provisions of Chapter9(commene- APPOANCISRESIDENTIAL JOB DESCRIPTIONingwith Section 7000)of Divleton3efthe Rusin and PmfeWmeCode,andmy _
license Is In full force and affect. PANELS
Llcensc Clam I,Icp
Date Contractor
ARCHITECTS DECLARATION 201-1001)AMT'S
M Zp I understand my plans shall be used as public record& OVERIWDAMPS SQ.FT.FLOOR AREA $/SQ.Ff.
6%z���`vvvj Lkwscd Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SI'ECIALCEtC /MISC
t., Ihereby affirmthat l am exempt from the Contractors License Law for the
Zo following reason.(Section 7031.5,Business and Professions Code:Any city or
OZF TEMP.METER O EI ST.
� county whichrryuir¢apermitrocomwd,alter,lmpmve,demolish,orrcpalr '
any structure prior to Its issuance,also requires the applicant for such permit to
ryE file a signed statement that he is licensed pursuant to the proviciona ELE of the POWER D
O O Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-
3 cion Sof the Business and ProfesslonsCode) I,or that he exempt therefrom and 5 NG C VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
QS aPPBantfor.pemdbubjectalheappficaettoa civil penalty offset murethan
five hundred dollars($SW). NE EN77A EC V
®1,a a owner of the pro",or my employees with wages a their sole SQ-FT- 57OWFS TYPECONSTRUCTION
compensation,will do the work,and the structure is not Intended or offered for
O Is 11ec.70"Bualness and Pm(esslora Code:The Contrartors License Law
$ don not apply to an owner of property who Wilds or improvestherebn,and
G who does such work himself or through his own employees,provided that such OCC.GROUT' RES.UNITS
Impmvementa are nm W endedoraffered fm Bale.IL however,the W ilding or TOTAL:
improvement issold withinoneyearolcomplation,the Owner-bullderwill have
fliLturden of proving that he did ren build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct iness the preject(Dec.7044,Busand Protractors Code:
The Contractor's License Lw does net apply to an owner of property who
WALTER-DRAIN&VENT-WATER(FA)
owlLebuilds or improves themun,and who contracts(or such ptukm with a
ctorU)Licensed pursuant to the Contractor's License Law. "FEE SUMMARY
I am exempt under Sec B&P C for this meant, BACK FLOW PROTECT.DEVICE
Owns DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Date 9
01
Aere RECEIPT 11
WORKMAN COMP SATION OECLto dIT FIXTURES.PER TRAP SCI IDOL TAX Y N
by affirm that I have a¢rt1(Iate of consentsent to self-Insure,ora RECEPT N
WOO,iaLab
C.) GAS EA.SYSTEM-11NCA OU-METS ofWerken'Comperwtlonlmuvn¢macertified mpy therm((Sec. -
WOO, PARK FFR Y N_
Policy p RECEIVE N
Com a GAS EA.SYSTEM-0VERN(E A)
Y BUILDING DIVISION FEES
Certeled copy N filed hereby
the cityed. GREASEANDUSMI,WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed ropy ls(Ikd with the city inspection division.
CERTIFICATE OF EXETIPTION FROM WOR KERS' GREASETRAP PAID 1
URA
COMPENSATIONINSURANCE
(This section need not b completed the SURApermit b(Drone hundred dollars SEN'FRSANITARYSTORM FA 200FT Date RCCeI I#
($100)°rless') WATER HEATERW/VFM/ELFLTR - ENERGY FEE Y N
I certify that N the performance of the week for which this permit fa laced, - —
I shall am employ any person In any manner an as to become subject to the WATIX SYSfGi/7RGHNC
Workera'Compensation Laws of California. Date PAID
0Z ApPBnt Date Recei t#
Z aO NOTICE TO APPLICANT:If,after making l his Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FP.
should become subject to the Workers'Compensation provisions of the Labor TOTAL: "
N Code,you must forthwith comply with such provisions arthis permit shall be IL IN
W j d¢mcd revoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE e
Z Ihereby affirm that thereiso mnstmctlean lending agency for the perform TOTAL: ELECTRIC FEE
r7 anmof the work for which this permit is Issued(Sec.3097,Civ.C.) ELECTRIC EEE
L) O Lenders Name
1L F Lender's Addmss QTY. MECHANICAL PERMIT, FEE MECHANICAL FEE
O W 1coklfy that l have read t his application.ad state that the above information
is correct.Iagree to comply with all city and county ordinances and orate laws PERMITISSUANCE FEES PAID: r
>. N relating to building onotmdlon,and hereby authorize representatives of this Za
Z city to enter upon the above-mentioned property fee inspection purposes. ALTER OR ADD TO MECH. Dale ReCei t#
V — (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabWties,judgments,meta and expenses which may In any myaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against said City In consequence of the granting of this permit CONSTRUCTION TAX
/J�y--`fie 5./ //a.-- MR HANDLING UNff(OVFR10,000CFM) '
51g.atturc.ffAApppp•Bcant/ContreaCctor ���e AIEXHAUSTHOOD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATING UMT(70100,(1W BTU) Date 'Reoei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Ilealth and Safety Code Sedlon2S532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: —3
❑ Yea M No
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent hazardous air contaminants as defined by the Bay Area Air PAID
• lity Management District? BOILER-COMP(31B'OR 100,000 BTU)
Yrs ❑No
shave read the hazardous materials requ Imments under Chapter 6.95 of BONER-COMP(OVER 100,000 DIU) MAR 081990
the Callfernla Health h Safety Code,Settlors 25505,25533 and 2553/.I
understand that 11 the Wilding does net mrmntly have a tenant,that it is my NEW RESIDEMIAL MECH. SQ.FI.
responsibility to notify the occupant of the requirements which moat be met �
prior to Issuance of a Certificate of Occupancy. City of na"Cone
Owner or authorized agent Date
TOTAL: ISSUED BY: t�__ [A U
OFFICE COPY