19399APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PFRMITNO.
ei_vD
19399
an,e
neon Marc:
T Sol 12 \"
CITY
OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
Contractors Name: Lie. Nx
BUILD INGELECTRICALPLUMBING.MLCHAMCAL
CATEGORY
CONTROL Nl—gt yD
Arehltect/En gineen.. Lie. No:
AINAkNsl C' F2
QTY
ELECTRIC PERMIT
FEE
BUILDING PERMIT INFO
Address:
..
PERh4TISSUANCE
.
❑ ❑ ❑
L ED CONTRACTOR'S DECLARATION
m that
Ihareretion 70that)ivstor,3dhe under
ofthe Buslaesand[srofeselonaCode,and my
Business sofChaptsCods, and
Ing with infull fame died.
license b In full force end e, N
License Clav Lk.a
Data Contractor
APPLIANCES-RESIDENTIAL
JOB DESCRR'DON
•- ( --��A. `G�- . f�C �/1D�2.
PANELS
PANELS
201 -1000 AMPS
ARCHITECTS DECLARATION
Ina eemt d [I�s haiLbbeuseda bllerecoryiy ..
Licensed ITr$�1 lH
OVERIW0AMPS
SQ. IT. FLOOR AREA
f /SQ. Fr.
SICN5 ELECTRICAL
OWNER - BUILDER DECLARATION
I hereby affirm that I am exempt fromthe Contractor's License Law for the
SPrCIALCIRC M
7EMP.METHROR E ksww
following mason. (Section 7011.5, Business and Pmfmions Code: Any city or
countywhich requires a permt to mmutma, alter, Impmve, dennith,orrepair
anyrtructure pdorto its issuance,aborequiresthe applicant for such permitto
file a signed statement that M b licensed pursuant to the provlsloou of the
Contndorb Llceae Law (Chapter 9 (commencing with Section 7000) of DIvi.
don 3 of the Businemand Pef.eloru Cod e) or that he is exempttherefromand
the bash for the alleged exemption. Any violation of Seaton 7031.5 by any
appllcant fora permt subjects the applica le nt a civil penalty of net more than
five hundred delta. ($500).
F1 I, as owner of the property, or my employees with wages as their wie
ppWpR DL'GICES
WANG L
OUTLE i
VAL�1Aa�7ON
O O O V
,
NEW R A
W FS
TYPE CONSTRUCTION
compensation, will do the work and the stmau re a not intended or offered for
sale (Sec. 7044, B.goess and Profemioa Code: The Contractor. Llceae law
r\
does not apply to an owner of property who builds or Improves thereon, and
who doessuch work himself orlhrough Ms own employees, provided that such
___MC
GROUP
RES. UNITS
improvement arc not Intended oroffered formic. If, however, thebuilding or
Improvement bwldwithlnoneyearofcomplmion ,theowner- bulWerwlll have
tiietia rden of proving that M did not build or improve for purpose of ask.).
U L as owner of the property, am exclusively contracting with B38aed
contncto. to construct the project (Sec. 7044, Business Professions Code:
QTY.
TOTAL:
PLUMBING PERMIT
FEE
PERMIT ISSUANCE
FLDOD ZONE
MIN
,
The Contractor'. License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ajeces with e
151 am pursuant to the Corrtncter's License Law.
151 am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT -WATER (EA)
BAIX FLOW PROTLCT. DEVICE
FEE SUMMARY
FECS
DRAINS FLOOR, ROOF, AREA, COND.
SANITARY Y N� -
RECEIPT #
Owner Date
1 WORK MAN COMPENSATION DECLARATION
I hereby affirm that I have of consent ro
FIXTURES, PER TRAP
SCHOOL TAX Y N
odir o Insurance copy (S a
38011 L.b Cj erken'Comperuatlanlauvnce oracertifled copy thereo ((Sec.
350c, Mb C.7 C
Policy #_
RECEIPT' #
GAS EA. SYSTEM -]INCA OUTLETS
PARK FGE Y— N
RI:CEdTp
GAS EA. SYS EMB OVER4(M
Coco any
BUIL DING DIVI SION ITES
Certified on t hereby to the city
citified mpy b herebyito the city inspection division.
WASTE INTERCEPTOR
PLANCHECKFEE n
(��
GREASE TRAP
CERTIHGTEOFEREMI'TION FROM WORKERS'
y})6Y
PAID 2 �la�'4s
goa`a`�
COMPENSATION INSURANCE
ITht section need not be<ompleled BtM permit b (Drone hundred dollars
Date Recd t#
SEWER. SAMTARY -STORM EA. YOOFT.
(5100)orfmJ
(certify that In the person in an the manner was t ob tom esubjec booed,
I shall not employ any person f any manner at ae to become subject to 1M
Workca Compeneetlon Laws of California. Date
WATER HEATER W /VENT /ELEOTR
ENERGYFEE Y N —
PAID
WATER SYSTEM /TREATING
NDIICHt
NOTICETO egib)CANT:e after nukingthis vation pir is Exemption you
Cade, you fort withce ply with s Lobar
Code, you must forthwith amply with each provisions or this permit shall be
deemed invoked.
Date RecCl t#
NEW RESIDENTIAL PLMB. SQFr.
TOTAL:
BUILDING ELE
xC39
TOTAL:
SEISMIC FEE
ELECTRIC FEE
uO
CONSTRUCTION LENDING AGENCY
Ihc.byaf0rm thatthem Is a construction lendlegagency forthe perform.
ance of the work for which this permit is blued (Sec. 3097, CIv. C.)
Lenders Name
Lenders Adder.
I certify that 1 )nave read this application end pate that the above Information
tcorred. I agree to comply withal) dty and county ordinances and state law.
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building cemtmction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an it keep harmless the City of Cu pert lno
ALTER OR ADD TO MFCH.
Date ReceI t#
aga lout habilltin,ju dgments, costs and expenses which may In any way acme
aga iat said City In mmsa)ueea of the granting of this permit.
AIR HANDLING UNIT (TO I O,ODO CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IQflBD CEM)
CONSTRUCTION TAX
'
Signature of Applieant /Contractor Date
EXHAUST HOOD(W /DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CFO 100,000 BTU)
Will the applicant or future budding occupantstore er handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 7, and the
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
s b
Health and Safety CodL.Srdlon 25537(a)7
F1 Yea No
VFNIILATION FAN (SINGLE RESID)
ISSUANCE DATE
Willtheapplican/ or future building ompant use equipment ordevices
which emit hazardous air contaminant as defined by the Bay Area Air
BOILER -COMP DHPOR 100,000 BTU)
Quality Management i�Mct7
4 Yes Iw No
INmaterlals
/� 1
BOILER-COMP (OVER 100,000 B1U)
have read the haz mquimments under Chapter 6.95 of
the Gllferida Health & Safety Code, Secilono 25505,25533 and 25539. 1
understand that if the building does not currently have a tenant, that it is my
responsibility to notify the empant of the requirements which which must be m
N JJV
NEW RESIDENTIAL MECH. SQ.Fr.
prior to issuance of�a Certificate of Occupancy.
Own. rautmN horlud agent � � 12/4
Data
��rr���
755UED BY:b 1JS� 9 ,.i�S�}- %�'G'4
1
TOTAL:
,OFFICE COPY