19663 APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY
Building Pro'edIdentification PEIMITNO.
BUBdmg AdJrea,: - _ 19663
F'oll �ClhGrw
wnersName: - Phone:
RU-T14 00,Nbe_ CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: _ Lic.No: APPLICATION I PERMIT ^
(rI_/ MASCf�/z 2I�S BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL It
ArchOed/Engineer. Lk.No '.,BUILPING PERMIT.INFO
Qrr r,. . ELCTRICPE'RMIT FEE
Address: PPRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment, APPUANCFSREMENTIAL JOB DESCRIPTION
Ingwlth Secdon 7000)o(Dlvlslon3ofthe BuslneesandPrd(esslonsCode,and my
license I.In fun foeffect. PANES
License Claes — and Lk.B A6 — O
Date Contractor G V�l�M 12
ARCHITECTS DECLARATION 201-i 000 AMPS Irl
NO Z I understand my plane shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA SQ.FT.
�q O
E� Licensed Professional SIGN5ELECTECAL
OWNER-BUILDER DECLARATION
jn SPECLILCIRCUIT/MISC
Z Lo., Iherem
byafBrm that Is. Contractor's License Law for the
O Z ti following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER ORPOLE INST.
countywhichmquimsapert ttommtmd,alteglmprove,demoll,h,orrepair
�,t'i anystm=m pdorto its issuance,aleorequmatheappllwnt forsuch permit to ppWgg DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
3 u, Contractor's License law(Chapter 9(commencing won with Section 7000)of Divi- VALUATION
SWIMMING IDOL ELECTRIC
SOS don3 ofthe Business and Professions Cods)orthat he ie exempt therefromand '
C the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIXTURES" /�C>(3, 0 L2
room
applicant into permit subjectsthe applicant to a civil penalty of not rre than t I
five hundred dollars(9500). Ise V
I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ. STORIES TYPE CONSTRUCTION
C
compensation,will do the work and the structure is m Hntended or offered for .,
5 O sale(Sec.7044.Business and Profeedons Cade:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCG GROUP RES.UNITS
who does such work himself orthrough his own employees,provided thatsuch
improvements are not Intended oroffered for sale.If,however,thebuliding or .TOTAL:
Improvement idsold within oneyearofcompletlogtheowner-buBderwill have
thUI,rden of proving that he did notbulld orlmprove forpurposeofeale) QTy, PLUMBING PERMIT .,FEE'.'.` FLODDZONE APN
as owner of the property,am exclusively contracting with licensed PERMI7755UANCE
contractors to emstfuct the project(Sec.7044,Business and Professloea Code:
The Contractors License Law does not apply to an owner of property who -ALTER-DRAIN&VENT-WATER(EA)
Wilds d
de or Improves thereon, and who contracts for such ptlajea with a FEE SUMMARY:
cr(R((actor(,)licen,M pursuant to the Contomme'sLicense Law.' i .ti
I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICEOUTSI DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT k
WORKMAN COMPENSATION DECLARATION TEXTURES- TRAP SCHOOL TAX Y N
711(hereby affirm that I have s certificate of of consent to self-Insure,ora RECEIPT B
arti(late o(Workere'Comperaauon lraurenceora certl(led copythereof(Sec. GAS EA.SYSTEM-1 INCA
OUTLETS PARK FEE Y N
Policy fa CJ RECEI'TB
Policy N GAS EA.SYSTEM-OVER 4IRA)
Cam any BUILDING DIVISION FEES
�Certmed copy is herefiled w Furnished.'
the city i GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
RI Certified copy b filed with the tlty inspection division.
W CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARI'STORM FA.200FT. Date Recei tit
(This aectlon need not be completed lithe perrok is forone hundred dollars
(5100)orlcss.)
I ceml...)t N the performance of thework(orwhkb Found,this permit sued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N_
I shall not employ any person in any manner an as to become subject to the WATER SYSTL'hf/TREATING
Workera'Compensatlon Laws of California.Date PAID'
O Z Applicant NEWRESIDENTTALPLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provision,of the Labor - 'TOTAL:
F W Code,you most forthwith comply with such provisions or this permit shall be '
W > deenad revoked. BUILDING '
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE I
M O I hereby affirmthat there Is a exrestructlon lending agency for the perform- TOTAL: ELECTRIC FEE
O anceoftheworkforwhichthlepermitisiasued(Sec.M97,Civ.C.) -
V Lenders Name • PLUMBING FEE
I— Lenaeraaaareee QTY:d ,MECHANICAL•:PERMIT ''...FEE':'
LL MECHANICAL FEE
OW lad ify that have read this application and state thatthe abovelnfor atlon
1 Is correct.I agraeto complywith all dlyand county ordinances and state laws PERMITISSUANCE FEES PAID: .
>. relatingtobulldingmestructlon,and herebyauthorice representatives ofthis ,
N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino - Date Reeeiptif
O against liabilities,judgments,costs and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
agerabald ityl con uenao he ranting ofthl,permit AIR HANDLING UNIT ROVER I0,000CFM) CONSTRUCTION TAX r
Signamore of Applicant Contract r Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the a ppilaoccupantnt or future building occupant store or hand ie hazardous HEATING UNIT(TO 100,000 BTU) Date ' Recet of
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health nand Safety Code Seiion 25532(a)7 HEATING UNIT(OVER 100,000 BM❑ TOTAL: .3 LEV
Will the applicant o�ctture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DA'L'E
which emit ha,mrdous air contaminants as defined by the Bay Area Air
Quality ManagementsMd7 BOILER-COMP 0HP OR 100,0(10 BTU) -
4Yea No
havc ad thehz EI materials requirements under Chapter 6.95 of BOILFR-COMP(OVIM 100,000 BTU)
the California Health&Safety Code,Sediom 25505,75533 and 755VE I
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
rrspoosibllity to notify the occupant of the requlremente which most be met p p
prior to Issuance of a Certificate of Occvpa ncy. yl`/ DF OrtnorlfPrp
Owner or authorized agent Dates
TOTAL: 1ISSUEERY:%j-
OFFICE COPY