19650 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN-ONLY
Buildin I'Wect Identification PERMITNO.
indmgAaareaa: 19650
2 r o 6 c2F—� �;1z. �C; �
wnera C7 Fence. APPLICAHONSUBMIIIALDAIE
��u��d Ic o56tJ f�iST CITY OFCUPERTINO-BUILDING DIVISION �_`
• G°��Li" : L+m N APPLICAT16N If PERMIT qO
r't BUfLDINC ELEC7RICALPLUMBING-MECILANICAL. CATEGORY CONTROL N
Architect/Eegl er. Cl He.No:
- BUILDING PER
,QTY,.. 7')ELECTRIGPHRMIT_,t TEE. - . ...,t .
Address: � � PERMITISSUANCE � �
LICENSED CONTRACTOR'S DECLARATION
I
hereby aMen,that l sm licensed under provisions o(Chapter 9(commene. APPLIANCES-RESIDENTIAL JOB DESCRI'7lON
iogwitleSetlion 7000)of Divislon3ofthe Bustessuand Penf eud er.Cods,and my
license Is In full force and effect. - PANELS .,
License CUss 'Lontr I ..�.T.e.[) C's••.s�s n '
Date Contractor
ARCHITECS DECLARATION 701-IMOAMP5
Det pz Iundentand my pT'lans shall W used as public mcorda OVERIo00AMPS'- SQ.FT.FLOOR AREA E/SQ.FT.
E LlcensPf Profayslona+ SIGNS ELECTRICAL -
+kRo OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
z�� thereby affirm that tam exempt from the Contractor's License Law for the -
p following mason.(Section 7071.5,Business and Professions Code:Any city or
F I-Pty countywhlchrequimsaper ttocorutruct,ate,impmve,de.lRh,orrepair TEMP.METER ORPOLE INST.
<� 3a anystrudurc prlrnto its lssuaricG a6o requires+he applicant fonuch permit to
+� V file a signed matement that he in
t9 licensed pursuant to the provces of the POWER DEVICES -
S:�G Contractor's License Law(Chapter 9(mmerencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC -
Mon3 of the Business and Professions Code)or that he It exempt therefroma nd VALUATEON
the bash for the alleged exemption. Any violation of Section 7031.5 by any
subjectsapplicant Ears permit subjects the applicant to a civil penalty,of not more,than OUTLEISSWITCHES-FIX ES
five hundred dollam($500), NEW RESIDENTIAL ELECTR
G7 F-]7,as owner of the property,or my employees with wages as their sole —�'IT STOWES TYPE CONSTRUCTION
rompensatlon,will D clothe work,and thestmcture Street Intended or offered for sale(Sec 7014 Hesitates and Professions Code:The Contractors License taw
S$ dome not apply to Me owner of property who Wilda or improves thereon,and OCC.GROUP RFS.fINITS
EE whodocesuchwark himuEorthragh hisownemp+oyees,provided that such
impmvemcntt are not intended oroffered for sale.IGhowevegthebulldlegor TOTAL: fl RO
imimprovement back!within oneyearofcompietion,theenver-builderwl+l have
e�urden of piecing that he did not Wild or Improve for purpose of sale.), QTy; '," k ApN.VIBINGPERMIT,{ r. FEE }TpOD 7pNF.
u1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ^
rontracton to romuwtl the project(Sec 7M6,Business and Professions Code: I Kx�'
The Contractor's License law cion net apply to an owner of property who ALM-DRAIN VENT.WATER(EA)
bWilds or Improv ,es theme and who contracts forp
such (ojects with a
m
bactor(.)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE t FEE SUMMARY
I am exempt under gee. B A P C for this matan
5111f'.FLCS..
Owner DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
• Data RLCI9Pf M
WORKMAN COMPENSATION DECLARATION FDrrURFS.PERTRAP SCHOOL TAX Y N
Of hereby affirm that I have a mrtlRca c of consent to op thereof or PIERTRAP
N
M0cert0,Laee(Workeri CampensaOonlnsuranre ora certified espy thereof(gee. GAS.En.SYSTEM-1 INCA OUTLETS
3800,[ab CJ �. PARKFM Y N '
Policy N
- RECEIPT N
Com any GAS G.SYSTFM-OVER4(EA) BUILDING DIVISION FEES
�Certlfled copy is hereby furnished. - - GREASE/INDUSTRL WASTE INTERCEPTOR' 'PLANCHECK FEE
❑Certified copy li filed with the city inspection division.
• CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
nor W co COMPENSATION INSURANCE SEWERSANITARYSIORM EA. Date Recei
(This section need Sat be completed lithe permit V furors hundred dollars p[N
(8100)orlessd WATRRHEATERW/VENT/ELECTR' ENERGYFEE. Y N
]aMi(y that In the performance Vote,
work for which sista pertnit la4med, � ,-
1 eh511 est empl n mon Inf(Cy�;;Is pa u o the WATER SYSTEM/TREATING
Workers'Com sa Y U, ate _Z,OD PAID -
O Z Applicant / Date' Recti tN
NEW RESIDENTIAL PLMB. IT.
Z O N077C$TOJMPLjCANt:e H en tion pro cion oft
eLyou —� '
should became subject to theWorkers'Compemationprovlalonsofthe Labor - TOTAL:
LU N deemedre meet forthwith amply with each provlalomu or thB permit shall be BUILDING FEE _
W j deemed revoked.
CL p - CONSTRUCTION Is a cory LENnwc ncENcv- - SEISMIC FEE
thereby Bork for Licht is Permit issued
3097, iv.C.)e perform TOTAL: M-^� ELECTRIC FEE
D Z acme!the work for which this permitRL+sued(Sec.3097,Civ.C.) - W
O O Iender.Nann 1. PLUMBING FEE . f}
U.0 O endmrsAddmIt QTY. MECHANICAL PERMIT'; FEE
O W Imrcltythat lluve readthbappBcetlonand&ate that theabove information MECHANICAL FEE
IL la correct.l agree to comply with all city and county ordinances and mate lawn PERMIT ISSUANCE FEES PAID:
r W relating tobuilding construction,and hereby authorize representatives o(thN -
Z city to enter upon the above-mentioned properly for inspection purposes. ALTURORADD7OMECH. ' -
- (We)agree to save,indemnify an d keep harmless the City of Cupertino Date RecelptN
against liabilities,judgments,mstsand expenses which may in anywayaccue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL'
agabu:t Bald Clt In con" e a the granting of pe IL -
AIRHANDLINGUNPr(OVERI000OCFM) - CONSTRUCTION TAX
S o Applicant/ etraclar ExHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS 'RIALSDISCLOSURE ,.
Will the applica ret or fust bol d Ing occupant score or handle hazardous HEATING UNIT(TO 100,000 BTU) -
.led.:as deft tied by the Cu Perrino Municipal Code,Chapter 9.17,and the Date p/�ReeeipIN -
He❑altla9d SifetyCode,Section 75537(a)7 HEATING UNIT(OVER 100,"BTU) e'd^LTOTP
Willtheipplieant or❑tuta-Wildingocepant uaseq.1pmentordevices VENTILATION FAN(SINGLE REBID)
which emit hazardous air mnt.nerenteas defined ISSUANCE DATE bythe Bay Area Air S I IDA
Quality Management District? BOILER-COMP OLI'OR 100,000 BTU),
n❑No
4haveVes read the hazardous materials requirements under Chapter6.95 of BOILER-COMP(OVER 100,1100 BTU) �y,r Og /+Ir.•nTti lift
the Glifrnis Health h Safety Code,Sections 25505,75533 and 75534.I It
understand that tithe building does not cermetly have a tenant,that it ismy NEWRESIDENTIALMECIL SQ.Fr. - -
csponsiMlitymnotify the occupant of the requirements which mumbemet - -
priortolssuanceefzCertiEca+eofOc panty.
" Owner or aulhoriud agent Date - ISSUED BY:..
TOTAL:
0FFICE COPY