19781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 19781 a�
nerd inns phone: A A A�h
CITY OF CUPERTINO-BUILDING DIVISION L
-: or'sN �LI APPLICATION /PERMIT q0
BUILDING-a ECTRICALPLUMBINGMECHAMCAL CA AY CONTROL p
Archimet, gineer: Lie.No:
^ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 11- PFRMITISSUANCE ❑ ❑ ❑
affirm that ED CONTRACTOR'S DECLARATION
Ihereby
ion700)of Division
oftheerprovisions ofesusadPm Chapter 9xdmand c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
tog with SMl.n7f100of DiWslon 3olthe BudnessandlPro(easionsCade,and my
License le In
UP dLk.MdlM lT TO2 /VI �V • �..�
Llcenr Ic
Date Contractor
ARCHITECPS DECLA ION 201-1000"PS
9770- l understand my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ,FT.
U Licensed Pmfessioal SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Zf' a Ihereby affirenthat I.exempt from the Contractor's License law for the
following reason.(5MIon 70115,Business and Professions Code:Any city or
P )' u9 countywhichrrypi aper tiomruh MR ter,impmve,demllsh,orrepalr TEMP'METER OR POLE INST.
�� Q anystmeture priosto its ussance,alsorequbee theapplicant f.rsuch permit to POWER DEVICES
M U file a algned statement that he is licensed pursuant to the provisions of the
O� Contractors License Law(Chapter 9(commending with Section 7000)of Divi- SWIMMING POOL ELECTRIC 0 al.n31dthe Business and ProfesslanaCode)either heis exempt therefmmand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
' p�sj' applicant for a permitsubjMa the applicant to a civil penalty of not morethan OUTLETSSWITCHESFIXTURES
p�Tjj�S,tc flue hundred dollars he pro NEW RESIDENTIAL ELECTR EQ,FT, STORIES TYPE CONSTRUCTION
n m I,as owner of the property,or he employees with wages r thele sole
compensation,7lon,Businesswill do workandiomCdureh not intended orofferedfor
sale(Sec.apply
to Business and f property
Code:The Contractors herein,License law
S$ don not apply to an owner of property who n builds or improve thereon,and ROUP RFS.UMTS
who doaeuchwork him I(orthrough his ownemploym,provldd that such
Improvements are not intended oroffered forests.If,however,thebullding or TOTAL:
Improvement u sold within aneyca r.fc.mpletiory the owner-W Bderwlll have
tlkeJ•vrd'n of proving that he did one bund or improve foe purpose of sale.). QTY. PLUMBING PERMIT FEE DZDNE nPN
Lj 1, a owner of the property,am exclusively coneraRing with-e.—
contractors to matmct the project(See 70K Business and Professions Code: PFRMITIESUANCE
TM Contrad.r.License Taw don net apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilde or Improves thereon,and who contracts for such pd
5ojes with a FEE SUMMARY
cgallactoRa)becrund pursuant to the Contractors License Law. BACK FLOWI'ROTECT.DEVICE
LI I am exempt under Sec. B&P C for this reason OUTSI
FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
[11 hereby KMENaffirm that I have a certificate of coment to self-Inwrc or a FLYTVRE_'PER TRAP SCHOOL TAX Y N
rtl(Icate of Workeri Qompemation Insurance or a certlfiM mpy themaf&e. RECEIPT R
3800,Feb C.) 1.��I�') L`� GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE YF Y N
P.IIry Y T _ _ _ RF-CETT N
Com any - GAS EA.SYBTFM-OVER4(EA) BUILDING DIVISION FEES
l�GfnlGed copy us led with
the cid. GREASEANDUSTRL WA5M INTERCEPTOR PLANCHECI(FEE
Lrttl,F rtified copy u filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlssecti.nneed not becomplet d lithe permit leforoahundred dollars SEWER-SANITARY-STORM EA.200FT. Date Recei t#
($100oeless) WATER HEATER W/VFNT/ELFCTR ENERGYFEE Y N
I mnot that inthe pedormanm.(the work for which this germine Ito the
I shall not employ any person in any nnn. co u to become subject to the WATFRSYSTEM/TREATING
W.rkcn'Compensation Paws o/Callfornla.Date PAID
O Z Applicant
Z 0 NOTICE TO APPLICANT:I,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT, Date Recei t#
Hshould become subject to the Woek<n''Comperuatlon Immloka of the Labor TOTAL:
CCN Code,You must forthwith comply with such provision or this permit shelf be
W > deemed rev.kd. BUILDING FEE
a C CONSTRUCTION LENDING AGENCY nETE
= Z Ihereby affirmthat there b a construct..lending agency for the pedore, Torn1: FEE
0 ante ofthe work for which this permit 0 issued(Sec.3097,Civ.C.)
O Lender.Name G FEE
LL Tender.naareee QTY. MECHANICAL PERMIT ITE ICAL FEE
O W Imrtlfy thatl have read thisapplicitlon and statethatthe abovelnformitlon aV correci.lagreeto comply with all cityand muntyordlanasand state laws PELMR65UANCE a :W relating to building convtmedoe,and hereby authorize representativesofthbZ city to enter u Pon the above-mentioned property for wpMlon purposes, ALTERORADDTOMECH.
(We)agree to save,Ind emNy an d keep harmless the City of Cu pen Inca Receipt#aga tat liabilities,judgncnts,ao<,and expenses which may in any way accrue AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL•Lsald City in con en .(the grant in of Wepermit. AIR HANDLING UNIT(OVER 10,000 CFM) CTION TAXSI tumof Applicant/ContractorDat EXHAUST HOOD(W/DUCT) CTION TAX PAID:HAZARDOUS MATE I LS DISCLO U EWilltheapplicantorfutumbullding pantstomor dle hazardousHEATING UMT(TO IOJ,000 BTI. i;FMmaterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the Recei t#
IIcalth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yes rJ No TOTAL:
Will the applicant or future building occupant use equipment or devices VFNI7LATTON FAN(SINGLE RESM) ISSUANCE DATE
which emit hazardous air contamieants as Bellnd by the Bay Area Air S A NC
Quality Management District? BOILER-COMP OFIP OR 100,"8 H
4Ya ❑No
have read the hazard Ova materials requirements under Ghaptn6.95 of BOILER-COMP(OVE 100,000BTU) OCT 2 6 "XV
the California Health&Safety Cade Sedloa 25505,25533 and 25534. I
unit creta nd that if the building does not mmently have a tenant,that it is my NEW RESIDENTIAL MECH. SQYT
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Oceupa ncy. city of CII
Owner.,xuth.nzed agent Date V
TOTAL: ISSUED BY: �`
OFFICE COPY