19579 APPLICANT.TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro'ee Identification PERMITNO.
Building Address: 19 5 7 9
izNil
cars ams: 1 —I I Phone: /
�( D.yr �2r•1—N Ej➢�SYIID CITY OF CUPERTIN0.6UIL DIV
actors Name: Uc,No: APPLIC, N PE M
o BUILDING-ELECTI BING- CATEGORY CONTROL N
Alibi- Architect/En�iteeeLlc.No:
I - qTY ELE ERM .E 'BUILDING PERMIT INFO
Address
PERMRISSUANCE :o ❑ ❑
LICENSED CONTRACTOR'S ARATIOK
Iherebyaffirmthat l am licensed under provisions o(Chapter 9(rommenc APPI.IANCESRF L &TI JOB DF FUFIION
Ingwith Sadton7000)of Division3ofthe Bualnemand Pm(msionaCode,and my
license is in full force ayd elect. P r
LlcenseCla® (`�1(-1 LION Rol
ARCHITECT'S DECLARATION 101-1000 PS 111
Z I understand my plans shall be used as public records. OVER 1 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional - 57GN5ELEC
6 OWNER-BUILDER DECLARATION
I"n � SPECIAL CIRCUIT/MISC
L,, Iherebyaffirm that lam exempt from the Contractor's License Law forthe
�o Q following reason.(Section 7MIS,Businrm and Profesiona Code:Any dty or
FaF'ty countywhlch requires a permit to constmd,alter,Improve,demolish,or repair TEMP METER ORPOLE MST.
anystructure pdortolts lesuance,alw requireslheapplant forsuch perMtm POWER DEVICES
' U file a signed statement that he Is licensed pursuant to the provisions of the
3µ Contractor's Lieerse Law(Chapter9(cmmencingwith Section 7000)of Divi- SWI HUNG POOL ELECTRIC
�O sion3 oftheBusbassand ProfessimaCode)orthat he is exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEI'SSWITCHFSFI%'D1RES y
O applicant lots permit subjects the applicant to a dvil penalty of not moretban -
five undreddollars($500). NEW RESIDENTIAL ELECTR roSQ.FT.
n 1,as owner of the property,or my employees with wages as thele sole STORIES TYPE CONSTRUCTION
C
c.unpareationwilldothe work andthe structure is not Intended or offered for
5 p sa1e(Sec.7061,Business and Prefemlow Code:The Contractors License Law
S$ does not apply to an owner of property who Wilda or improves thereon,and OCC CROUP RFS.UNITS
doessuchwork himselforthrough hisown employees,provided that such ]
Improvements are not intended orofferedforsale.11,hmvever,thebuildingor TOTAL: a]
Improvement issold withinoneyearofcomplenogtheowner-buOderwill have
t rdenofproving that he did nm build or Improve for purpose ofaale.). Qty, PLUMBING PERMIT FEE '
�I,as owner of the proFLOOD ZONE APNperty,am exclusively contracting with licensed
roPERMIT ISSUANCE
ntnctore to construct the project(Sec.7066,Business and Professions Cade:
The Contractors Llcenss Law does not apply to an owner of property who
WALTER-DRAIN&VENT-WATER(EA)
ilds or Improves thereon, and who rontnct.for such pk.*U with a
cgR[factor(s)licensed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I�l I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,ARG,COND. SANITARY Y N�
Owner J Date RECEIIxTN
WORKMAN COMPENSATION DECLARATION FXTURFSPERTRNa SCHOOLTA% Y N
❑I hereby affirm that I have a coni@an of consent ntil to pythe of ora REcEpr M
ceniRate o(Workera Compensatlonlruurance oracenifled copythereo((Sec. GAS EA.SYSEM-1 INCA OUTLETS PARK FEE Y N
3800,Iab 7 ----1a r�
i'ol. 10v�t� GAS EA.SYSTEM-OVER 4(PA) DINGRECEDI p
Com any t 1f'hAfi�♦f'IQ/Y BUILDING DIVISION FEES
Certified copy 'film (u sed. GREASE/INDU5TRL WASTE INTERCEPTOR PLANCIIECICFEE
�enifled ropy is(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP PAID
COMPENSATION INSURANCE SLIVER-SAMM TARYSTOREA 200Fi. Date Recei t#
(I'hissection need not be completed If the permit is for one hundred dollars
($100).H..) WATER HEATER W/VENT/ELCCTR ENERGY FEE Y N
I certlfythat In the performance of thework forwhich this permit is Issued, —
I shall not employ any person In any manner so as to become subject to the WATCR SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
-
Z Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date RCCeI f#
O NOTICE TO APPLICANT:I,after mak l ng this a tfiLim of Exemption,you
Hshould become subject to the Workers'Compensation provisions oftha Labor TOTAL:
a. r'A Cade,you=at Forthwith comply with such provisions orthis pemdtshall be
dermad revoked. IN
FLE
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
Z IhambyafOrtnthat there is a construction lending agency for the perform TOTAL: ELECTRIC FEE Q
ance.(the work(or which this permit is Issued(Sec.3097,CIv.C.) '
Q O Lander.Name PLUMBING FEE
LL F- Lander.Addnas QTY. • MECHANICAL PERMIT FEE MECHANICAL FEE
O W I ceve
rtifythzt l havereadthis application and nate thetheaboinformatlon
1 iscorrect.I agree to comply with all dty and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building roretmdion,and hereby authorize rcp..tativ. fthis
H to enter upon the abovementloned property for Inspection purposes. ALTER OR ADD TO MECH.
Z city Inspection Date Reeei 6#
_ (We)agree to save,Indemnify an d lump hadess the City of Cupertino
against liabilities,judgments,costs and expenses which may In any way amus AIR HANDLING UNIT CFO 10,"CFM) SUBTOTAL: IMP
a�airtvt..iCCltylmmnsayu ceoft antingofthl permit.
( \u MRHANDLINGUNIT(OVER 1o,ro0CF1,) CONSTRUCTION TAX
Signature of Applicant/Contractor Data IXFiAIS"f HOOD(W/DlJC'D CONSTRUCTION TAX PAID:
HAZARDOUSMA IALSDISC URE
Will the appllcant or future building occupant store or ba rad Is hazardous HFATING UNIT(TO 100,00)BTU) Date ReCei IN
natedal as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Flealth and Safety Coda Section 25531(a)? I(EATING UNIT(OVER 100,000 BTU) TOTAL:
EI Yes No
Will lheappllcant or turebullding occupant use equipment ordevicas VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air rontamiwnts a defined by the Bay Area Air -
Quality Management District? BOILER-COMP OW OR 100,000 BTU)
Yes n❑No 6
Fh.veread the hazmou.materials raquImmenborder Ch.pier 6.95of BOILER COMP(OVER 100,000 BTU) MAY � 5 �(1QQ7 0
the California Health k Si fey Code,Sections 15505,2SM3 and 75571. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.I7.
responsibility to rad ify the occupant of the requirements which riwst be mel
prior to issuance of a Certificate of Occupancy. Cltp of Nir,irt10(1
Owner or authorized agent Data TOTAL: ISSUEDBY:� c VGL- c
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OFFICE COPY