19327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prnba Identification PLILWTNO.
Build
irg Addreies: Goi/ 19327
y-e�re ante: M I� Phone:
ejQQI PMefT_ CITY OF CUPERTINO-BUILDING DIVISION _
cmuractora Name: Lie.No: APPLICATION / PERMIT 7
BUILDINC-ELECTRICALML BING-MECHANICAL CA RY CONTROL N
Lte
Architact/ gin r: . U [
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: U E rr I PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby effirtn thatlam llemsed under provblons ofChaptcr9(mmmmc- APPLIANCES-RESIDENTIAL JOB DESCRI'HON
ingwith Section 7000)of Dwidon3ofthe Busmossand ProfesdoesCodc,and my
urease b in mu fQ�e am errea. �91a.4 So rnNF3s
License am.s] Corti
Date i(mm��YYfOa Lic.# ctar�C�C>,o�,S..-_
—UP TO 200 AMES
ARCHITECTS DECLARATION 701.1000A.NPS
02 I understand my plans shall be used as public recordw
dOVER 1000 AMPS SQ.FI.FLOOR AREA f/SO.F(.
CO
t, Licensed Professional SIGNS ELECTRICAL
�¢FX OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Iherebyafrirm that l am exempt fmm the Contractors License Law for the
70.9 H W following reason.(Section 70715 m,Busineand Professions Code:Any cityor TEMP.M=OR POLE INST.
�Z county which requimsa permit toconstruct,alter,improve,demollsh,orrepair
1�1 any structure prior to Its Issuance,also requires the applicant for such permit to POWER DEVICES
5 rile a signed statement that he Is licensed pursuant to the provisions of the
Q3c`I"n Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O sion 3 ofthe Business and Professions Code)orthat he b exempt themfromand rr
the bast+for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHESFIXI'URES D ••�
F5 appliant foray nontsubjens the applicant to a civil penaltyofnat more than
v>, five hundred dollars($500). NEWRFSIDENTIALELECTR SQ.FE. STORIES 7YPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sale
7_a rompensati. ,willelothe work and thestructere b not intended or offered for
O sale(Sec.7044,Business and Pronasions Code:The Contractors License Law
docs not apply to an owner of property who Wilda or Improves thereon,and l7CC.CROU1s RIS.IJNfI'S
whodoessuchworkhimself orthrough hisoweempleyees,provided that such
Improvements am not Intended oroffered for sale.If,however,thebuilaing or - T L:
improvement b sold within oneysarofcompldlon,the owner-builderw111 have
tlB,�urden of proving that he did not Wild or improve for purpose of asled. QTY. PLUMBING PERMIT FEE p1AODTDNE APN
U I,as owner of the property,am exclusively contracting with licensed pr"IT ISSUANCE
contractors to mnstmct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WA (E)"
Wma
ilds or Improves thern, and who contracts for such p,ajects with a FEE SUMMARY
C1Bf(adarts)licensed pursuant to the Contractor's License Law. BACKFLOW PROTECT.D
EVIC �✓
LJ I am exempt under Sec B &P C for this reason
ss j SANITARY Y
Owner Date DRAIN R ROOF,AREA,COND. N_
y RFLQIR,#
WOR KMAN COMPENSATION DECLARATION pIXTU4rSCHODLTAx Y_ N_
❑1 hereby affirm that 1 have a certifiam of consent to ontlAnsure,or .. `-
RECEIPT N
certificate of Workers'Compensatlon Insurance or a ecAlfied mpythereof(Sex. GAS EA MING.#OUTL �S� PARK FIX. Y #—
3800,Tab CJ RBCE97 N
Policy# GASEA. -0VER<(EA) II BUILDING DIVISION FEES
ny
(Certified copy b hereby furnished.
GREASE/W U L ASTE'INTERCFPTOR lC ,,�/ �I ertified copy b filed with the city inspection division. PLANCI-IECIC FEE
r e
CERTIFICATE OF LYEMPI'ION FROM WORKERS'
GREASE e,1 PAID1� STIJ-Z 36brS3
COMPENSATION INSURANCE SEINER-SANITARY SIORMSA ' () Date RCCCI t#
(fhissection need not W completed lithe permit is forons hundred dollars r'�
(f10D)or)ess.) ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued, WATER IiFATER W/VENT/ IR —
I shall not employ any Person in any manner an as to become subject to theW B}'STEM/TRIA NG PAID
Worker%Compensation Lawsof Califomla.Date
OZ Applicant DEN
TIAL SOFT. Date ReceI It#
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,
you
should become subject to the Workers'Compensation provblons of the Labor TOTAL:
CO Code,you must forthwith comply with such provisions or this permit shall be BUILDING EE Rl
S j deemed revoked. SEISMIC FEE
W CONSTRUCTION LENDING AGENCY
CL C Thereby affirmthat
cukf ,w Jchth6 construction lending 0W.Civfor the perform- TOTAL: ELECTRIC FEE
7 Z anceer's Nwork!or which thio permit'sblued(See 3097.CIv.CJ
U O Lender's NamePLUMBING FEE
LL H I,enaera naareaa QTY. MECHANICAL PERMIT FEE MECHANICALFEE
W bmImttfylhatl have read thbappliationana stamthatthealxwomformation
O rrect.I agreetocomplywith all cityand muntyordinances and state laws PERMIT ISSUANCE FEES PAID:
} C rela{dng to building construction,and hereby awhorim representatives of this
H Z city ea enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cu ped Ino O AIA HANDLING UNIT(!010,000 CFM)against liabilities, costs and expenses which may in any wayaccrue SUBTOTAL:
againOam City in mnecluence of the granting or this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CM)
Sigvture of Applicant/GU IXFi
Date EXHAUSTHOOD(W/DUCT) CtoNON TAX rA
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant.otdemur or handlehu'zrdoue HEATING OMT(T0100,000 BTIA Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
AI a lth and Safety Code Section 25537(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes ,1 No
ill the applicant oQtum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) I$$UA T1s DATE
which emit lui.rdousair mntamiruntsas defined by the Bay Area Air
Quality Management District? BOILER-COMP OFT'OR 100,019 BTU)
pQ YcsI—I No
"ZTAAaave read the hav us materials requirements underChapter 6.95 of BOILER-COME(OVER 100,000 RTU)
the California Health&Safety Code,Sections 75505,25533 and 25514.1
understand that lithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.Ff. a,
respone ibllily to notify the occupant or the requirements which must W met Cil'/ 'IF (srin?rtIBO
prior to Issuance of a Certificate of Occupancy.
` S3-1.50 1 7
Owner oraulhorlr� Dale ISSUED RY:�1 L
TOTAL:
OFFICE COPY