19815 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building project Identification PFTtMITNO.
Buddin AAdmss:� -
i $ � T 19815
neva me: Phone: --
VwAu, CITY OF CUPERTINO-BUILDING DIVISION
c etrecor'.Name: //ec.N. APPLICATION / PERMIT• _v'��'" BU/LDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL '
Ancitect/E,ginser.
- ' 'BUILDINGTERMIT INFO- -
- 'QTY:". ,,r�'".ELECTRIC_PERMIT.' + PEE��'
Addecsi: ' . PERMITIS5UANCE - /�
LICENSED CONTRACTOR'S DECLARATION E �-1`t El
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPOANCESRFSIDENTIAL A JOB DESCRIPTION
Incense I.in falI4 )ofd effect !the Busineasand Pro/esslonsCode,and my
Linela In fu— 11 stress n 3 8 PANELS
License Cis Li[.N !! '
Dale Contractor AN yAjV _ACAS,0' 0.11!
ARCHITECTS DECLARATION 201-1000AMPS -
K 7 1 understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA
pp�itu 00.
k� Licensed Professional SIGNS ELECTRICAL "
rid 6 OWNER-BUILDER DECLARATION
Iii a SPECIALCIRCUIT/M
71-'vI I hereby afOrm that I amexempt from the Contractor's License Law fur the
Q - following reason.(Section 70315,Business and Professions Code:Anycityor
rSl countywhich requlresMm+otr
aperttouctalteq m
improve,deollehor
, eepalr TEMP.M. OR LE INST.
w4� any structure prior to Its Issuance,also require.the applicant for such permit to
ContractoPOWER DE
y s.1 file a signed statement that he is licensed pursuant to the provisions of the
3 w
�OS cion 3 of the B..1 essand Pec/essloro Code)orth.t be la,exempt thererromand
r's Lteescse Law(Chapter 9(commencing with Section 7000)of Divl-
'G1 LELEC77tIC VALUATION
0 ti the basis for the alleged exemption. Any vloladon of Section 7031.5 by any applicant!...permit subjects the applicant to a civil penalty of ns.more thanFDTAES
punt$
five hundred asrcwnerofthepr. WR q EL SQ.Fr. STORIES TYPE CONSTRUCTION
❑I,as owner ll the property,or my employees with wages r their sole
.1.&
compensation,Boston,.andothe d
Preheat..
strode:Th Cmdexet nded or offered for
.1.&.apply
to alnan ow andf property
Code:The ConaprewYe License Law
does$$ whod.asuch orkh[owner of so nemplyuilds or i s,p .thereon,and OCC.GROUP RES.UNITS
whodoem nts am khlmsended orwgh hbownemp,hrxv,provided that vetch
Improvements sonot Intended earof o !.sale.](haveveg deer ldi hget ave TOTAL:
improvementBwid within oneyearolcompleli.n,tbe owner-bullderwlll have ,
thS_I,urdenof proving that he did not build or improve for purpose,orsao. QTY. 'PLUMBIN PER IAF ,t•TGE �, FLOOD ZONE APN
I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE UD
contractors to construct the project(Sec.7094,Business and Professions Code; 01
The Contractor's License Law does na apply to an owner ofproperty who ALTER-DRAIN kVENT-WATER(CA)
Wild. or improves thereon,and who contracts for such projects with e
cgDfradmix)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY -
LJ I am exempt under Sec. B k P C for this reason
Owner 8 DRAINS FT.00R ROOF,AREA,COND. / U O SANITARY Y N
® Date G RECEIPT N
WOR KMANCOMPENSATION DECLARATION FIXTURES PER TRAP O'� SCHOOL TA% Y_ N
01 hereby affirm that I have a certificate of consent to self-inwre,or a RECEIPT p
certificate of Workers Compecautloninsurance ora amifl.d copytheredf(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C
1'oilcyp GAS EA. RFC�a
% v :( �f. BUILDING DIVISION FEES
enl0eg copy heed with
the xdL
city GREASE/INDUSTRL WASTE IbITERCO'IOR PLANCHECK FEE
�Certifled copy l9(lied with the city Ivpectlan dlvlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION COMPENSATION INSURANCEo - -
(Thia.ectlon need not becompleled lithe permit is for one hundred dollare SEWER-SANITARY-STORM EA.3f%1FT. V DRIC RCCCI I#
($t6B)oleettifyth I WATER HEATER W/VENT/O.ECTR y.0, ENERGY FEE Y N -
allamthallnthnpets.I.aoftmans,an as to whlch
eermlject I.t sed, —
I shag not employ any person in any manner eo az to became subjett to the WATER SYSTW/.TREATING V
Workers Compensation Laws.o(Gllfomla.Date , �• PAID
O Z Applicant NEW RESIDENTIAL PLMB.__SQFf, Date Reset t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers Compensation provisions ofthe Labor 'TOTAL:,
'� A) Code,youmustforthwith comply with such provisions or this permit shall be BUILDING PEE
> deemed revoked.
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhercbyatOrmthat there is a construction lendingagenry forthe perform u ELECTRIC FEE
M Z ance orthe wo.kfor which this permit is issued(Sec.3097,Civ,C.) .TOTAL:
(.) 0 Leader'sN.meAL PLUMBING FEE efo
U. F Lender'sAddress QA MECHANICPERMIT' FEE, MECHANICAL FEE
OW 1c.rtifythat l have macithbapplicatlonand statethatthe above information
0. Iscornect.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N mirepresentative.
. u
} sting to building construction,and hereby aur's,re
thopresentative.of the ���� I
F Z city to enter upon t he aWve-minspection property for pection purposes. ALTERORADDTOMECH.- bate
(We)agree to save,indemnify an d keep harmless the City of Cu pen ino - DRte Recei t#
V agafoat liabilities,judgrrcnh,cost.and..per.which may in say wayaccrue AIR HA NDLING UNIT(TO 10,000 CIM) SUBTOTAL;
ago irut Bald City In consequence of the gra sting or this permit. -
MRHANDLINGUNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor - Date D(HAIISTEIOOD(W/DUCT) ' CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building omrpant store or handle hazardous HEATING UNIT HU)I00,0D0 BTU) -
materialasdefined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recei t#
Health and Safety Code Section 25534(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ox-7 IF
❑Yes Q No
Will the applicant orfuture Wilding occupant itis equipment.rdevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamin ars as dented by the Bay Area Air
Qua lity Management D'i'ct7 BOILER-COMp(3t1I'OR 100,ODT RTU)
4Yes �j%7y�Na
havemad the
ealth&TfetyCoerlabrequiremenb5533anunder hapter6.95.f BO LER-COMP(OVER]00,000BiU) J
the Czlifornlalt I(th building
Code, of ext nuctlyhave.
ve.t and75534.1
to ersta JliJA lit he Wilding doe s.curz quircoaveat h h that icmet NEW REST DENTIAL MECH. SQFf
resportsibib on try tis pa raft requlremenq whicatbemet
PH to a c ' .Cert toot anry. /
Owner .r lid agent•; Daex
'- TOTAL: ISS .D BY:
OFFICE COPY.