19659 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification - PERMIT NO.
Building Add mss:' _
1.
4- netsName: Phone:
FFr—QVIPA� 'A-} >¢B CITY OF CUPERTINO-BUILDING DIVISION -
Contra :me - Lm. e: APPLICATION III
PERMIT
a CATEGORY - CONTROL M
+ BUILDING-ELFLTRICA4PLUMBING-MLCHAMCAL
Archi ct/Gglncer. Llc.No:
QIY •''• ELECTRIC PERMIT ,_ LC, "� i�';BUILDING PERMIT INFO
Address: 74 ' _ PERVITISSUANCE ❑ ED LICENSED CONTRACTOR'S DECLARATION _ _
Thereby affirm that lam licensed under prmvWona of Cha(ner9(commene- APPLIANCESRESIDENTIAL JOB DESCRB'ITON
Ingwlth5 dion7000)oftXvi9ion3ofthe Businessand Professions Code,andmy ,
Iicenseis In fuR force and elfes. .. PANELS
License ClassLontr
Date Cmntresor UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
X ZO +• I understand my plane shall be used as public records. OVER HOO AMPS SQ.hT.FLOOR AREA 5/SQ.FT.
p�
d� Licensed Professional SIGNS ELEC AL'
�<¢
OWN
DECLARATION SPECIAL C T/MLSC
E. Z I hembyafBrm that l am exempt from the Contractors License law for the
Q county hichoquirection70it toomelnessand Improve,
demolish
ystyor
�<�E'� countywhkhrequlresapermittocomtruct,alter,Improve,demoWh,orrepalr TEMP.MWOR POLE IN
KE aryemud..prior to its lssuance,abo requires the applicant forsuch per, 0 pOWp-RD� CES
�gO a s file a signed statement that he Is licensed pursuant to the provisions of the
x Contractors License law(Chapter 9(mr.scing with Section 7000)of Divl-
El03 ston3olthe Busine dProfemiom CMe)orthathe Nexinpttherefmmand SWTMMINGJOOLEAqU& VALUATION
Sn the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE7SSWITCHFS %TURFS
<i appEcant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NEW RISID ELP.CTR
1,as owner of the property,or my employees with wages as their sole SQ.T' 'STORIES ' TYPE CONSTRUCTION
compensatlon,wBldothe work and thestmeture is not Intended or offered for
❑
sale(Sec.7074.Business and Professiora Code:The Contractors Liceme law
( $$ does not apply to an owner of property who builds or improves thereom and OCC,GROUP RES.UNHS
who does suchwork himselfor through his own employees,provided that such
improvements are not Intended mattered for sale.](however,thebuliding or TOTAL. '� �
improvementisaoldwithinoneyearolcomplelon,the owner-builderwill have - - .
thn„4urdenof provingthat hedid rwtbulid or improve for purpose of sale.), QTY. PLU7v1BING PERMIT 'FEE. ' FLOOD ZONE ppN
u7,as owner of the property,am exclusively contracting with llcensed PERMITISSUANCE x/yam
rors ntraetoW mmtruct the project(Sec 7014,Businessand ProfeasbresCode.no Contractors License raw does not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who'contracts for such projects with a
coy[pctor(e)Ilcenaed punuent to the Contratlor'e License Law. BACK BLOW PROTECT.DEVICE 'FEESUMMARY
LII am exempt under Sec. B& PC for thN mason
DRAINS FLOG ROOP,A SANITARY Y N
• (honer Date R AREA COND. RECEITN
WORKMAN COMPENSATION DECLARATION -
FIT hereby affirm that I have a certlBnFIX'[VRES PER TRAP SCI100L TAX
te of consent to self-Insure,or Y NRECEPf N
certificate ofWorkerte Compematlonlmurance or a cerifled copythereof(See. GAS FA. INCA 3800,Iab C.) PARK ITL Y_ N_ ,
Pali p — REC
Com any GAS EA.SYSTEM-OVER4(FA) 'BUILDING FRES
Cert lRed copy is hereby furnished. - _
E]Certifiedcopy le filed with the city Inspection division. - GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE -
CERTIFICATEOFEXEMPTION FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE
.(Thlssedionneed not becompleted if thepermdt lsforonehundred dollar SEVER-SANITARY-STORM FA.200FT: Date Recei t#
($100)ofyth) WATER HEATER W/VENT/ELECIR ENERGY FEE Y N
Icertifythat In the Performance ofthe work for which this permit is WUN, //fryy�s —
I shall not em
ploy y rwn In any user so as to come veb' t 1M WATER SYSTEM/TREATING .L.a.,W PAID
Workere'C roa eo 11 A, Date
O Z Applicant P
Z O
NOTICE.
L- ngl a !irate of Gemption,you
NEN RESIDENTIAL PLMIE SOFT Date Recel t#
Hshould becemeaubject to the Workers'Comperuatlon pruvlslomof the Lallbebor - TOTAL:
N . Code,you mustfmrthwith comply with euchprovbimm orthh permit sha
lL > deemed revoked. BUI I G EE
Q. CONSTRUCTION iINDING AGENCY - SEISMIC FEE
Ihercbyeftlrm that there laecomtroctlon lendingag:nc forthe Isrform. - TOTAL: ELECTRIC FEE
Z once of the work which this permit la issued(Sec.3097,C1v.C.) (� -
V O Tamer.None - ` PLUMBING FEE
LL I— Lenders Address - QTY. " ' MECHANICABPERMIT IT ' MECHANICAL FEE
O W Icertllythatlhavercad thLs appBcetlOn and state thatthealrove Information
fl Iscomed.I agree to comply with all city and county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
T relaBngtobuildingronstruction,and hembyauthmlze representatives of this
?W city to enter upon the abovo-mentioned property for inspersion purposes. ALTEtORADDTOMECH.
(We)agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
V against liabilities,Judgments,cosesand expenses which may In anywayaccrue AIR HANDLING UNIT(rO 10,ODOCFM)
agoug ova in. "'onh ntmg of this permit. SUBTOTAL:
AIR HANDLING UNIT(OVER IQ0JXCFM)- CONSTRUCTION TAX
siont (p,AI sta
ba-1EXHAUST xooD(W/DUCT) CONSTRUCTION TAX PAID:
AHADOUSMATER
DISCLOSURE
Will the applicant or future building pant store or handle hazardous HEATING UNIT(TO I OQ000 BTU) -
material as defined by the Cupertino Municipa l Cod e,Chapter 9.12,and the _ Dale RCeei t#
Health and SafetyCode�+.�Section 25532(:)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
C3 Yos u No r
Wllitheappilcant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RES ID) ISSUATE•
which emit hazardous air contaNnants as defined by the Bay Area Air NCEfDA
. Quality Management District? - BOILER-COMP(3FR'OR10gIX0BTU) ' '1
Yes �No
have read the hazyousmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER10),000 BTU) ' 11
the Califormiz Health&SafetyCode,SMlom 25505,25533 and 25534.1
understand that if the building does not currently have:tenant,that it is my NEW RESIDFNTIAL MECI I. SQ.IT. (sr
responsibility to notify the occupant of the requirements whlchmustbercet 'Ica re "11—rNo .
priorto Lsua race of a Certificate of Ocrupanry.
Owner or authorized agent Uate TOTAL: ISSUED`BYTOE—Z—PL30J
OFFICE COPY