19693 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pwiect Wentlflotlon PERMIT NO.
Building Adogss: 1969371s`
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nero arse. Phone:
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/[ N SSD- CITY OF CUPERTINO-BUILDING DIVISION ^b
Cono-ador's arse: Lic.N. APPLICATION /PERMIT _`�
ArehltM/Engineer. Lice No: 6
BULLDINGELECIRICAI.PLUMBING-MECFNMCAL CATEGORY CONTROL#,-I"/
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..
❑LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE El
I hereby ection 7Da0atlamlkensed 3Ofthaerpcss a,d ofChaptar APA
NCESRESIDENTfAL ]OB DESCRIPLION
Inensei In FOIL 90 W)ofd died. fthe8usinessand ProfexlonsCode,end my
license le In(u3 force and died. S
License Class LlcpBdY '_n �zjW
Date Contractorsr)/ l Lel-L�\y�•1[7
ARCHITECTS DECLARATION DAMPS
KO ]undcmtand n Ilos.hallba uxdu blicrecorels 000AMP5
O Y P PuSQ.Fr.FLOOR AREA $/SQ.FT.
d o Licensed Prof emlonal LECTRICAL
661 OWNER-BUILDER DECLARATION L CIRCUIT/
Ep. a I hereby affirm that I am exempt from the Contractor's License Law for the
OLFfollowing reason(Section 7WIS,Business and Professions Code:Any city or MEITA Oft I'OL I ST.
Q� countywhi&mquimaper ttoconstr d,alter,Imptove,demolish,orrepalr
K g.0 anyatructure pricrto its issuance,also requlmthe applicantfor such permit to DEVICES
O
file a signed statement that he b licensed pursuant to the provisions of the
3 a Contractor's License Law(Chapter 9(commencing with Section 700p)of Divi- NG POOL ELEion3 ofthe Business and PrefeasbnsCode)orthat hebexempttherefromandVALUATIONthe basis for the a11egM exemption. Any WWatton of Section 7WIS by anyppfiant for a perMtsubjis the applicant to a civil penalty a not more thanSV.7TCHFS live hundred dollars($50�. DENTIA L JImo( I,as owner Of the property,ormy employers with wages aatMir soleSSQ. STO TYI'ECONSTRUCTION
(o-m"persauon,will do the work and the structure is not intended or offered for
O sale(Sec 7004,Buslnem and Prfessims,Code:The Cotrad.es License Law
does nM apply to aa owner of Property who builds or Improves thereon,andOCC.GROUIa RFSUNTES
who doessuch work himself mthrough his own employees,provided that suchimproveme arenotintendedorofferedforsale.1(howeverthebuildingorTOTAL:impmvementlsaoldwithlnoneyearofcomplmW,theowner-bu0derwilllivetl�c�ardenofpmving that he did nmWildorimpmveforpurpmeofsak.). QTYUMBING PERMIT FEE FLOOD ZONE
L j L as Owner of the pmperty,am exclusively contracting with Ikcnsed APN
rontactorstOconstmdthepm)M(Snc.7044,Bualnesvand Professlo®Code PERMTTISSUANCE
The Contractor's License Taw does not apply to an owner W property who
builds or Improves eda thereon,and who centomo,for such pWjwith a ALTER-DRAIN&VENT-WATER(EA)
" Tactors)licensed pursuant to the COntradols Llcense Law.
M so
I am exempt under Sce. B k P C for this man BACKFLOW PROTECT.DEVICE FEE SUMMARY
-k OUTSIDE FITS
Owner p.,.. Data 1:i 9 D DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEBT#
WO C MPENSATIONDECLAR ION
❑I hereby affirm that I have a certificate of consent to self-Insure,or a FIXTURFS-PER TRAP SCHOOL TAX Y N
cerlflate o(Workers'CompensatlOn Insuranm ora certlfkd copytherro((Sec. RECELpT a
3800,lab CJ GAS EA.SYSTEM-I INCAOUTLETS PARK FEE Y N
Polley# RECID'f#
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDINGDIVISION FEf:S
�CMlfied copy k hereby furnlabed.
❑CMified ropy k filed With the city inspection division. GREASE/INDUS'IRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF L'REMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
(TMsxction need not becompldad lithe permit Hfm.m hundred dollars SEWER-SAMTARY-STORM EA.200Ff. Date Remi t#
(5100)mlesaJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
1 certify that to the person I. of Nework for Which this permit cissued,
I shall not employ any person f any manner so as to become arbjtt[to the
Worlica Compenaatlon Gsva of California.Date WATER SYSTEM/TREATING PAID
Z O NOTICE TO APPLICANT:H,after making this Certlflale of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date RCCYI f#
Fsbwld becomeaubj pct tO the Workers'Comperwtlon provisions of the Labor TOTAL:
N Code,you must forthwith comply with such prevklo®ortht,pamnitshallbe
Ll aeern,d rewked. BUILDING FEE -()o
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is.construction lending agency for the perform
Z I f7
anm of the work for which this permit is fsaued(Sec.309'/,CIv.CJ TOTAL: ELECTRIC FEE
UO Lender'shame PLUMBING FEE
LL I- Lender'.Address QTY. MECHANICAL PERMIT FEE
O W Icertlfythatlbve mallhlsappllatbn andmatethattheabove Nformatlon MECHANICAL FEE 0
S lacer<.l agree to comply with all cky and county ordinances and mate lawn PERMITISSUANCE Z,O0 FEES PAID:
N relating to building construction,and hereby authorize repmentativea of this
Z cityto enter upon the above-mentioned property for Inspection purposes, r ALTER OR ADD TO MECH. - U0
O — (We)agree to save,Indemrdfy an d keep harmless the City of Cupertino Date Receipt#
agalnstllabillties,judgments,cornsend expenses which may In any wayacaue AIR HANDLING UNIT(o 10,0D0 CFM)
agawt said City k cone unnce of he gram mg of permit, SUBTOTAL:
C/-a�riR AIR HANDLiNGUNIT(OVER,00DOCTM) CONSTRUCTION TAX
sig L',rc ( rppcant/Contactor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Rem t#
Itralth and Safety Cod,Section 25532(a)i HEATING UMT(OVER 100,000 B'CU)
❑Y. ri No TOTAL:
Will thezpplicant or future building occupant use equipment.,devices VENTILATION FAN(SINGLE RFSID) L�SI�Qp7CE DATE
which emit her rdous air contaminants as depned by the Bay Area Air rr,/y/V
ality Management District? BOILER-COMP pFB'pR 100,000 BILI)
Ya 1 I�No Ann
10
have read the hazardous materials requimments under Chapter 6.95 of BOILER-COMP 10QD00 BTU) 177V
the California Health A Safety Code,Sections 25505,25533 and 25534. 1 a aV I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. - ' I
rmpomubility to notify the occupant of the regWmments which most W met
priorioLuance Wa CertificateofOccupancy. ca#..E(f ret orfipft
Owner or autbodud agent Data I�rrII
TOTAL�( ,A6 ISSUED BY:
OFFICE COPY