19846 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prosed Identification 7 PERMIT NO.
Building Address:
Sq „ (RE 54/ LL- c7- 19846
r+ ante. Phos
tI 2- �+.---. A A A
/T- OJ T �'[x l�(V �pU3 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name Lk.No: APPLICATION I PERMIT
e✓ IAQ BUILDINGaDCTRICALPLUMBING-MFL}IAMCAL CATEGORY CONTROL N
Archit /Engineee Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreve
PERMITISSUANCE ❑ ❑ �•I ❑
Len that ED CONTRACTOR'S DECLARATION 17X"1
I herebySactvoirm )ofE)mBor3ofhecensed er Butdessalonsof Cssions9de,and c APPLIANCESREADENrIAl JOB DESCRB'fION
ingwith i fon7000)ofd lied,n3 olthe BuelnessandPro(esslonaCode,and my
license is In fuB��9'zj� k.#' O , —p.3 PANELS
Limnsu Class C_�)ILLk.Na O ���/�
Date,,:!['— 2 9_9a Cor-der���1♦YAa((T,
ARCHITEGPSD CLARATMN 2111.1000 AMPS
{q+� O I understand my plans shall be used u public records. OVER 1000 AMPS / SQ.FT. R AREA I E/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
<� OWNER-BUILDER DECLARATION SPECIAL CItCUfT ISC
I hereby affirm that I am exempt from the Contractor's License Law for the
O":'a following eason.(Section7MIS,Bminessand Professions Code:And or
O Z M y9 w r Y b' TEMP.METERO L IN
Fm9a, countyhichrequlresapermitlomratrud,alter,improve,demollsh,orrepalr
G any+tmdurepriortoltsissuancgaL m-qutre+theappUmntfmsurhpermvto P:0gR@EVICES
}E{ 1 O file a signed statement that he is licensed pursuant to the provbioms of the
iEf a can 3 on the Buicense siness end Pmfnukne,Coder 9 d ort ht hens exempt
9heerre0fromand SW1Mh9NG POOL ELE C VALUATION
a`� '.J the bass for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXTURES
0 applicant for a permit subjedstheappllcant to a civil penalty d no more than
ppb five hundred dollars($SM.j NEW RESIDENTIAL ELECTR�n ❑1,as owner of the property,or my employees with wages as their sok SQFL STORES TYPE CONSTRUCTION
mpensation,will dothe work and thestmdum is not Intended or offered for
o sale(Sec.7044,Business and Professore Code:The Contractors License law
[j5$ does not apply to an owner of property who Wilds or improves therms,and OCCGROUP RES.IINR$
0.0. whodoes suchworkhionelforthmugh hbown employees,provided that such
Improvemenb are not Intended oroffered lorwle.I(however thebuiidingor TOTAL:
Improvement bsold withN one yearof complNioq the owner-builderwlll have
t rden of proving that he did nm build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD7ANE. APN
4 as owner of the property,am exclusively contracting with Formed PERMIT ISSUANCE
contractors to mnstrud the project(Sec.7044,Business,and professions Code:
TM Contractor's License Law does not apply to an owner of property who
buALTER-DAMN&VENT-WATER(FA)
builds or improves thereon,and who contracts for such pkojecis with a
Cqut ador(s)licensed pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this mason
Owner Date DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION �a/a RECEIPT N
ce
I QI hereby silicon that I have a rtificate of consent to self-insure,or a Q FIXTURES PER TRAP �00`o SCHOOL TAX Y_ N—
on ilicateofWorkers Compemtionlmuwnworacertifkdcopythereof(Sea RECEB'TN
3800,lab CJ GAS EA.SYSTEM-1 INCAOUTLEIS PARK FEE Y N
PollryaN RECEIPT#
Com ray GAS EA.SYSTEM.OVER 4(EA) BUILDING DIVISION FEES
90 Cert fid copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
YCertlRnd copy b filed with the city inspection division.
Y" CERTIFICATE OFF EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhbsectionneed ndbecompidedifth¢permit bforonehundmddonnr+ SEWER-SANITARY-STORM EA.M)Fr. Date Recei t#
($100)mri th WATER HFATERW/VENT/M TR ENERGY FEE Y N_
Ill-We employ
the performanceny miwork fo as to bthiopermitc to the —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workere'Compewation Laws o(Callfomla.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._SQFF Date Recei t#
shmld become subjM to the Workers Compensation provisions of the Labor~ TOTAL:N Code,You most forthwith comply with such provisions,orthis permit shall be
W > deemed revoked. BUILDING FEE
d F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
Tof theherebyaorkfor ttherebamrotrudlonlending(Sec. ag7,Civ. .) perform TOTAL: 91 4 ELECTRIC FEE
0 an I hereby
work for which this Is constpermit isissued(Sec. agent for
U Lender's Name PLUMBING FEE
LL Lander's Addm++ QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icadl(ythaithavereadthisnpplicatlomnd statethattheabove Information
4 mrred.lagree to comply with all city and county ordinances and state laws PERMIT156DANCE' FEE—PAID:
} N relatingtobullding comtmdbn,and hereby authorise representatives ofthis
N Z city to enter upon the above.mentionM property fm WpecHon purposes. ALTERORADDIOMECH.
(We)agme to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,ends and expenses which may In anywayamue AIRHANDLINGUNIT(rO10,000CFM)
agairL'sl wi@d ery/,1 ryuenm ofthe grammg otthi�pertniE SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
--biignsure of AlppBont/ otractor Date EXHAUST FLOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building oovpant store or handle hazardous HEATING UNIT(TO 100,000 BM
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the _ Date Recti t#
I❑Yes
d Safety CodreL�pSe��n25532(a)7 HEATING UNTT(OVER IOWD00 BTUI TOTAL: Q
Will the applicant odfE building ocmpant use equipment or devices VEMILATION FAN(SINGLE RESID) ISSUANCE DATE
�
which emit hdvanIOOs air contamN
ina rats as defined by the Bay Area Air
Quality Management District? B011211-COMP(3FIPOR 100,000 BTU) RPR!
4Y. No p o
have niaHeah &Safe� Code,materiabtions2menbundeand255r6.9Sof BO LER-COMP(OV727 p, 00 BTU) ,131AY 2' 91990
the California Healthk5alety Code,Sections 25505,75533 and 2Si34. I F} `�
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFT.
responsibility to notify the occupant of the requirements which most be met Ns�
prior to issuance of care of Occupancy. Ae{tt VL
ye _9 SRV 9SILL {dl
own—c o:a�t, c..wA!� �j—7 21eJ F-- �`.
TOTAL: ISSUED BY:.
OFFICE COPY J