19606 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Ruilding Potted Identification PERMITNO.
Building Add ress: 19606
D _ E CAu T Cu r.10 CA-
nera
[a1TFt1� VI ME1� CO CITY OF CUPERTINO-BUILDINGDIVISION
en annra �� 3ie.No: APPLICATION I PERMIT
hitM/� BUILDINGELECTMCALd'LUMBINGMECHAh7CALqff CATEGORY CONTROLN
gluxr: k Lk.No:
1n� R♦LAL QTY ELECTRICPERMIT FE`Es� BUILDING P ERMITINFO
Address 4 % Ir&O b PERMIT ISSUANCE w ❑ D.
El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section 70M)of DMsion3ofthe Businewand Profession Code,and my
license b in fifilforce and effect. PANELS
Llcen Chas, _ Ltc0 I 1 aAa�`� G✓
Datc O Contractor
ARCHITEC7PSDECLARATION G used
201"1000 AMPS
07 I understand my plans shall be ud as public records. TIzK- OVER 1030 AMPS SQ.FT.FLUOR ARE $/SQ. FT.
LE ®
2 Licensed Professional SIGNS ELECTRICAL
C OWNERx NLDER DECLARATION T E R
jn SPECIALCIiCUIT/MLSC
p, , Thereby affirm that lam exempt ct
xempt from the Crntraor'e License Law for the
X.2 "QQ� following reason.(Section 7031.5,Business and Professions Code:Any city or U
K BPR rountywhichrequimapermittommtr d,Oter,impmve,de=llsh,orrepair TG1P.METER ORPOLE]NST. I •�
�Va anystructure pdorto Its lssuance,alao requiresthe applicant for such permit to POWER DEVICES
O F V file a signed statement that he b licensed pursuant to the previsions of the
w� Contractor's License Law(Chapter 9(commencing with Section 7000)of Dlvi- SWIMMING POOL ELECTRIC
sion3ofthe Business and ProfessionsCode)orthat he is exempttherefromand VALUATION
y3„ the basis for the alleged exemption. Any violation of Section 7031.5 by any
a^ applicant fora permit subjeRslhnapplkanttoactWl pevOUTLETSS WTTCHE&FIXTURES lty of no mom A
rr o five bund red d ollars($SM. NEW RESIDENTIAL ELECTR
�j ❑1,as owner of the property,or my employers with wages as their sole �'�' STOW FS TYPE CONSI'ROCTION
compensation,will do the wmk and the structure is not Intended or offend for
sale(SaagW4,Business and Profusions Cade:The Contradoes License Law
(rj$$ does not apply to an owner of property who builds or improves lherem,and OCC.GROUT' RIS.UNITS
who does such work himself or through his own employem,provided thatauch 2
Improvements r notintendedorofferedfo role.I(hrven,gthe Wildinger TOTAL: J co
Improvement Is sold within oneyearofcomplelion,the owner-bullderwill have
tl(,karden of proving that he did not build or Improve for purpose of saln), QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LJ,den
owner of the property,am exclusively contracting with licensed PERMITLSSUANCE
contractors to comtrua the project(Sec 7014,Business and Professions Code:
The Contractor's Llmnee law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilda or Improves thereov,and who contracts for such ptojects with a
co actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPTN
WOR KMAN COMPENSATION DECLARATION FIX'IVRFS PER TRAP
5CIT)OLTAX Y_ N_
hereby af(Irm that 1 have a artifkate of consent to self-insure,ora RFGk]PT N
<nl0ote of Workeri Compereatton lnsuranceora unified copy themof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.)
RECEIPT N
Policy N GAS.EA.SYSTEM.OVER 4(EA) BUILDING DIVISION FEES
Com a
�L�erriiified copy Ls heed with the
city GREASE/INDUSML WASTE INTERCEPTOR PLANCHECIC FEE
Cenlfied copy i9 filed with the tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEW ER SAMTARXSItJRM G.200FT. Date ReceI t#
(fhisxdion need cot W completed 1f the permit b forom hundred dollars
($i W)orI..) WATER HEATER W/VENT/ELFLTR ENERGY FEE Y_ N_
I certify that In the performance of the wmk for which this permit is issued,
I shall not employ any person In any manner as as to become subject to the WATER SYSTEM/TREATING
Wurkem'Compensatlmn Laws of California. Date PAID
OZ Appllant NEW RESIDENTIAL PLM°. SQFT. Date Recel t#
Z O NOTICE TO APPLICANT.]Laher ma king this Certifiateof Exemption,you
should become subject to the Workers'Comperuation provisions of the Labor TOTAL:
CC 0 Cod,you at forthwith comply with such provisions orthts pemdtshAlbe BUILDING FE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE _
CL Ihemby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z arca of the work for which thin permit ix Issued(Sec.3097,Civ.C.)
f, O la.dara Name PLUMBING FEE
Lenders Addrea QTY. MECHANICAL PERMIT FEE
LL U 1cenlfythat l have read this appliczttonand state that theabove information MECHANICAL FEE
O W is cornet[.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
d relating to building comlrucdon,and herebyauthorlaimpersentativeso!thin
H N city to enter upon the above-nantlomd property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,pdgmemi,evstsand expenses which may in anywayaccrue AIR HANDLING UNIT UO 10,000 CFM) SUBTOTAL:
agarol said City In consequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDUNITNG UN (OVER 10,000CFM)
Signature of Appllant/Contracter Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wit l the a ppllca nt orfulure building occu pant store or hand le haraodoua HEATING UNIT CIO 303,000 BTU) Date Reeei tit
material as defined by the Cupentna Municipal Code,Chapter 933 and the
I lealth and Safely Code Section 25532(a)? EIEATING UNIT(OVER 100,000 BTU) TOTAL: -b OO
❑Yes N No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? POILFR-COMP OIIP OR 100,000 BTU)
Yes M No
_ Thave,read the haaa' ous materials requirements under Chapter 6.95 of BOILER-COMP(OVEt 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1
u aderstarad that if the building does not currently have a tarsal,that it is my NEW RESIDENTIAL MECH. SQ.M. V
responsibility to not By the occupant of the requirements which must be met
prior to ksua ace of a Certificate of Occupa ncy. PLA35
Owner or authorized agent Date TOTAL: ISSUED BYV�%QYu`ti �
OFFICE COPY