20471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address: _ f7 O /I 9
Z 7145 e, 1. G G 4
�4f5
1A�C .tCITY OF CUPERTINO-BUILDING DIVISION. q
ec'mcmr'e Name: Lit.No: .' APPLICATION I PERMIT �"'^ -2, [
,II I BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL'66Z7
Arahltect/Engineer•. Lie.No: G
-' ' '" I " '--' . BUILDIN_ CIP,ERMITINFO-
- ELECTRICPERMJT, FEE',!" -
Acidness: PERMITISSUA E rl A
LICENSED CONTRACTOR'S DECLARATION �. f3
Ihereby affirm that l am licensed under provWons of Chapter 9(commose, APPLIANCES DE L JOB DESC ON
Ingwlth Secion7000)of DiWslon3ofthe Businessand ProfesdoesCode,and my
license is In full force and effect
PANELS - ..
Lienee Clam Lie# DAkA
Date Contractor - KIP '
ARCHITECPS DECLARATION 201-1 0 IS —tt
OZ I understand reyplatushall be used sat public records. O OW SQ.ITOR.FLOOR AREA S/SQ,FT.
+ �OO Licensed Professional NSEL CAL,
Q OWNER-BUILDER DECLARATION S IRC
U1T/MISC '
7 t"' Iherebyaffirmthal lamexempt from the Contractor'•Lie,rse Lawf th
oo following reason.(Section 70I1S,Business and Professions Code:Any ct or
Oz� count hlchreuiresa rmit toceratru alteq lm edemolbh,err Pair
METE ORPOLEINST.
F E Ysv 9 a cL Prov, P
S a nyatructurcprbrtolts Lsauance,alsorequlrntheappEcant forsuch permitm pO DEVICES '
6 V ilk a signed statement that he Is licensed pursuant to the provision of the
Contractor's License Law(Chapter9(mmmencing with Section 7000)of Dlvl- VALUATION
Yrs SWIMMING POOL ELECTRIC O
sion3 oRhe the alleged
d exemption. Any violation
he of exempt therefrom and D
6 the bash for the alleged exemption. Any violation of Section am one es any "1 OUTLETSSWITCHESFl%TURES _Z,� Z s
applicantfora permit subjects the.pidicant too civil penalty of na rrorethan Va- 7 S''- ��
fiundred dollam($500). NEW RESIDENTIALELECTR SQ.FT. STORIES TYPECONSTRUCTION'
LLL111 1,as owmr of the property,or my employees with wages as their sole
7¢ compensation,wthdothe work,and the structure is notintended or offend for
does❑ sale(get.apply
Bu siness and Professions Code:The Contractors thence,
- V
$$
who does
apply torn owner ofthroug hison lds mporimprovnthmeagand OCC.GROUI RES.UNITS
w prover ,nmuch am work himself ed orough hisnwnemIt,hes s, er,vided thatthebuildi such
Improvemnnti and within oneprofferedforsale.[(however, deer ilIhave TOTAL:
i provementissold within oneyearorcompletion,theowner-buliddrwill have
tiMIarden of pet that he,did not build or improve for purpose ofsale.). QTY „"',PLUMBINCPERMIT ' t ' I-13 RpODZONE APN -
LJ L as owner of the property,am eaelusively mntrading with licensed PERMITISSUANCE
contractors to rorotruct the pm*d(Sec.7064,Business and Professions Cade: �_Vis
The Commcter's License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
bullas or Improves thereon, and who contracts for such projects with a FEE SUMMARY
rop(Tacor(s)licensed pursuant to the Contractor.Lt...Law. BACK FLOW PROTECT.DEVICE
LII am eaempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owraz Q Data RECEIPT#
VOIIIIGAAN COMPENSATION DECLARATION py%T'UREIS-PER TRAP� SCIglX3l'IA% Y - N—
f.
❑I hereby affirm that I have a certificate of convent to self-Imre,ora � � RECEIPT#
certificate ofWorkem'Compensation Insurance macertlfled ropy thereofeiec. GAS EA.SYSTFM-1 INCA OUTLETS PARK FEE Y N.
3800,Lab C.) —
RECEI T#
Policy tl GAS EA.SYSTEM-OVER 6(EA)
Com any R UI LDING DI VI SI ON FIT ES
❑pCertified copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE d
❑cenmea ropy Is cora with the city inspection division. ! /S
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(ISEWER-SANITARY-STORM EA.200Ff. Date ReEi f#
hisaection nerd not be compldted:(the permit V(�rone hundred dollen P
($1IX)o11ess.) ENERGYFEE .Y N S'f -
IcertilythatintheperformenreofthewmkforwhichthlapeonitlsW ed, WATER HEATER w/VFNf/O,ECTR �V
I shall not employ any pereon In any manner w n to become subject to the WATER SYSTEM/TREATING
Worker:Compensation Lawsol California. Date PAID
-
zZ Applicant NEW RESID@JITAL PIMB, SQ.Ff. Date Recel t#
Z O NOUCETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compereation provisions of the Labor TOT
W Cade,you=at forthwith comply with such provisions orthls permit shall be BUILDING FEE IT-z3-V6
W j deemed revoked.
CONSTRUCTION LENDING AGENCY - _ SEISMIC FEE .Z f
a_C , [hereby affirm.,it for
the acomituctlon lendingagenry .C.) perform - ELECTRIC FEE
Z Lenders Name forwhkhlhb permitVlssued(Sec.3097,Cly.CJ TOTAL: �.17� .Z0
V O Lender's Name , s - _ .,, PLUMBING FEE r - D/1
1L 1- Lender's Address - - QTY. • _ MECHANICAL PERMIT " `,FEE.„ MECHANICAL FEE - .Q
OW - I artifythat l have read thisapplicationand state thattheabove Information ��""
0. u correct l agree to comply with all city and county ordinances and state taws PERMITISSUANCE (a✓�Vy FEES PAID:
} N relating to building construction,and hereby authorize representatives ofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTIRORADDTOMECH. Date ReCeIPI#
— (We)agree to save,mdemnlfy an d keep harndew the Clty of Cupedno i
against liabilities,Judgments,cremand expenses which may In anywaya N 10, 'SUBTOTAL:
a t.14�Cily in consryueaceof the gmatingof this Permit. ,
713 d c CONSTRUCTION TAX
Sig mof Applicant/Contractor -Date T IOD /D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE • -
Willtheapplicant orfutum building occupant store or handle hazardous HFAITN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date RCCej t#
health
Yea e4
Safety Cade,Sectio 25532(a)7 FIFA GUNIT(OVCR BT -TOTAL:
[329 2Z
Ill the applicant m❑future building occupant use equipment ordevices VENTILATION PAN ANGLE ISSUANCE DATE
which emit haszrdous air contanneare as defined by the Bay Area Alr OAR®,
Quality Management District? BOILER-COMP OI1P DR 1 W,IXq BTU) t�'"'##�ra�i
Yea �1�7I No
"Thavercadthebazar`Ti pus materials requirements under Chapter&95 of BOILER-COMP(OVER100,000 BTU) .14JtJ
the Cahfornla l lealth A Safety Code,Sect ions 25505,75533 and 25534.7 ('•(.�., tf, t�
understand that lithe building does not currently have a tenant,that it is my NEWRESIDEMIALMECH. ' sSQ.FF
responsibility to notify the occupant of the requirements which=at be met
prior to Issuance rtiRcam^ forre�anry. City,of Cupertino
Owner or authorised agent Date
' TOTAL: V ISSUED BY.
OFFICE COPY