19367 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bnid�nrg.cid bo Q e z-r 19367
wneroa Phone: -
( CITY OF CUPERTINO-BUILDING DIVISION
centrad 'Name: LIc.No: APPLICATION (PERMIT
Architect/En BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL it1.
glneer: LIc.N : •] 7
A5 G }— QTY ELECTRICPERMIT e•(FEE BUILDING PERMIT INFO
AddMIECH
ress � P LQ PERMBTISSUANCE , c. �jT ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LSI
I hereby offirm that l am licensed under provisions of Chapter9(commenc- APPLIANCES-RESIDENTIAL ]OBDESCRII'ITON
Ingwlth Sed1on7000)of Dlvislon3ofthe Buslnemand PmfemlonsCode,and my
license i In full force and effect. PANELS M
License Ctam
Date CControrm
actor UP TO 200AMPS
ARCHITECTS DECLARATION 201-1000 AMPS
+p�+0000
I urcivaltandj}/y plans el�Bbe ^ubB=rda. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k� Licerawpurfessional f SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCNT/MISC
Thereby a(Orm
that Iam exempt from the Contender's License law for the
po following reason.(Section 7021.5,Busincee and Professions Code:An cityor
�Z county which requires a permit to construct,alter,Improve,demolish,or repair TSP'MFTM OR POLE LIST.
any otrumme prior to its lama ace,also requires the applicant for such permit to POWER DEVICES Q (�
O file a signed statement that he Is Banned pursuant to the provisions of the a
Contractor's License (ChapterLaw 9(mmencin ithSection 7IXp)ofDivi.�OS sion3ofthe Buslnessand Profem
m
ioCode)orthat he besempttherefromand SWIMMING POOL ELECTRIC viat,� VALUATIaNtl
the basis for the alleged exemption. Any violation of Section 7031.5 by any
x05
applicant fora pedtaubjece,the applicant to a civil penalty of not than OUTLETSSWITCHFSHXTURFS / � Q O
m
five hundred delta.($500).
1,as owner of the ro NCW RESIDENTIALELECTR SQ.FT, STORIES TYPECONSTRUCTTON
C7� O nsallon,willdo the work andt my
b amlint Intended orofferedfor
$J p sale(Sec.704L Busb,eas and Pro(esslons Code:The Conl.dora License Law
EIS$ does nM apply to an owner of property who Wilds or improves thereon,and
CC.• who daesauchwork himselforthrough his own employees,provided that such OCC,GROUT' R[S.IWIT5
lmprove.manls are not intended oroffered for sale.If,however,thebullding or TOTAL; ^
Improvement taeold withinoneyearofmmplellon theowner-buBderwlll have 1•�
tggkurden of proving that he did not build or improve for purpose of sate.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ 4 an owner of the property,am exclusively contracting with humsed PERMIT ISSUANCEmnt.cto.to construct s the project(Sec.7044,Business and Pro(essimCode:
The Contractor'.License Lew does nut apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves theme.,and who contracts, for for such p(ojewith a
,fit et (a)licensed pursuant to the Contractor.License Law. gA�p�WpROTLCT.DEVICE FEE SUMMARYL2(am exempt under Sec B k P C for thin reason
Owner DRAINS-FLOOR,ROOF,AREA,COND. SANITARY Y N_
Date RDCEI T R
WORKMAN COMPENSATION DECLARATION pLX PER TRAP SCHOOL TAX Y— N
❑[her affirm that I have a certificate of consent to self-Insure,a a
cenifiateofWorke CompemaHonlmuranmo acertlfiNmpythereof(Sec. R��,X
WC.40U7LLT5 I
3800,1.6 C.) C SYSFEM-1 lea PARK FEE Y— N
Policy kRECEIPT N
Com an G SEA:SYSTEM-OVER4(EA)�1
Y BUILDING DI VISION Fr.ES
Certified ropy Is
� furnished.Cenified copy with the city Wpectlon division. - lPLANCHECKFEE
_ / er
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFAS PAID �2 a
COMPENSATION INSURANCE SEWER- STORM EA 200FT Date Recei t#
(fhb section need end be completed lithe pemdt ta Ionone hundred dollars
($100)orless3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent that Teniae performance ofthework(orwhichthio permit is Issued, —
I shall not employ any peen In any manner an as to become subject to the WATER SYSTEM/TREATING
Workcre'Compenaatlon Lawn of Gll(omta. Date PAID
O Z ApplicaNOTICE` Date Recd t#
Z O NOTICEco a bCANT:e Workers
rsmaking Compensation
icons oftof the
-
NEW RESIDENTIAL PLMe. SQ.FT.
1" Code,shoulyou
fort wit the Workert Cumpensatbns orchis permit s Lab or TOTAL:
W deemed
mustforthwithcomply with such provisions or this permit shall be
> deemed revoked. BUIL ING •• •
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE x
I hereby a(firrnthat there Is a construction trading agency for the E
F
E
perform-
7 Z ance ofthe work for which thin permit b bound(See.3097,CIv.C.) TOTAL: ELECTRIC LEEE
VOlender's Nome
LL I— Lenders Address QTY. MECHANICAL PERMIT : ... FEE MECHANICAL FEE
OW Icestlfythatl have reacithisappllcallon and statelhatthe above Information
IL Iscormd.I agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>_ relating to building construction,and hereby authorize representatives ofthis
N
H U) city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei t#
_ (We)agree to save,Indemnify an d keep harmless the City of Cu ped Ina P
against liabilities,judgname,mets and expenses which may In any way name AIR HANDLING UNIT CFO Ins10,000 CFM) SUBTOTAL;
ago t said City in consequence of the granting of this permit
AIR HANDLING UNIT(OVER I Betio CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date IXHAUST HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HA ZA IFDOLS MATERIALS DISCLOSURE
Will the applicant or future building acupant store or handle hazardous HEATING UNIT(TO 100,000 BT U) Date Reeei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Cod a Section 25537(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL: L
RYes M No
ill the applicant orfmim Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSD E
which emit haraAom air mntandnants as defined by the Bay Area Air
Quality Management District? BOMER-COMPOFT'OR 100,000 BTU) rend , 5 1990
4n Yea n❑No
have read the hazarcloue materials rcqulrcrnents under Chapter 6.95 of BOILER-CAMP(OVEA 100,000 BTU)
the California Health A Safety Code,Sections 25505,25S33 and 25534.1
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. ary• --!!j
responsibility,to notify the occupant of the requirements which must be mot
prior to Issuance of a Certificate of Occr pa ncy.
Owner or authorized agent Date ISSUED BY: �l
TOTAL: I
OFFICE COPY