19996 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY rill
Ruwin Pm era demlfbtlon PERMT NO.
Building Adak: a s e�d o r 19996.
Op quits S°-t S —G _
one: A
Finc—u
K Ci-QpU, CITY OF CUPERTINO-BUILDING DIVISION
Connectors Name: Lb.No APPLICATION / PERMIT G
Amhhect/Engineer. No: BUILINNGFlBC7RICALI'LUMBINGMF�FIANICAL CATEGORY �Co�_L
1
4_ —S 6l b BUILDING PERMIT INFO
// - QTY ELECTRIC PERMIT FEE
AAddress, (00 S s SlG PEIMTISSUANCE
LICENSED CONTRACTOR'S DECLARATION '� 0 0 0
,hereby affirm thatlam lkenaM sassier pnovlelans of Chapter 9(mmmet APPUANC6RESIDENTIAL JOB DESCRETION
Ing with Section 70M)of Division 3ofthe It".and Proledos Code,and myn�UH p�J
Ikense E N full force and effect. PANELS
LI¢nae Gla» C36 LkF �iH
D+Ie�fi ITE EC Tman�M Lani cal
ARCHITECTS D.public
OVER1
q�v WQ❑O❑ Iurdemtand my pbs shall be asci npubac rcaorda OVER 1090 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
la y f) Lbsed Professional SIGNSELECTRICAI.
<� OWNER-BUILDER DECLARATION
Ilu,ebyaflrenthatlameumpt fromthe Contractor's Lleenae Lawf¢the SPEECIALC[RCUIT/MLSC
Fg ❑� following re..l"ictlon 7MIS,Buelnes.eA Profession,Cade Any city or
� auntywhlchnqu4 spec tomrutmdalter,Impr ,demo h,orrepair TEMP.METER OR OLEINST.
O5 anyatm=mprlmtolts ww ahorequtr theappBantfmsuchpermhto POWER DMCE5 ,
0 Ole a signed statement that he Is licensed pueeuant to the provisions,of the _
r Contract ,
U^ ie LAw(Chapter9(commencing with Section 7009)of Dlvl-
SWAM NG POOL F1 FCTRIC
lb andPmfesbvCode)orthatheempeeefromM VALUATION
the basis for the alleged exemption. Any nidation of Section 7031S by any
applicant forapenmitubjectstheappB ttuadvllpanaltyofnat more t ban OUTLETSSWTCHESFIXTURES
five hundred dollars%M%. NEW RHSTDENTIAL ELFLTR Ff.
GGQQ1l �n ❑I,as owner of the property,or my employees with wages u their sole SIORIES M'ECONSTRUCTION
compensation,w81 do the work,and the structure is rot brerded or offered for
a�aa n rale(Sec 7011,Buslrcu and Professions Code:The Contractors License Taw
ns$ doe not apply to an owsr of property who builds,or Improves thercoR and OCC.GROUP RIS.UNITS
CE. whodceasuchworkhimslfmthrwgh Naownempl y.,provbedthatsudr
improvements are of Intended oroffered forsale.If,however,the building or TOTAL
improsxmem bsdd whhlnoo yearofcompletbM1 then wner-bullderwBl have
t"rde,,a proving that be dm not baud or Improve for purpose of sale.). QTY, - PLUMBING PERMIT FEE
u L as,owner of the pmperty,am exclusively�tractNg with licensed FLOOD ZONE APN
mntractora to corwtmdthe project(Sec.7014,Business and Professions Code: PERMIT MUANCE /'a OQ
The Contractor's impr'o es the Lew doe not apply to an owner of property who ALTER-DRAIN k VET f-WATER(EV
bu0ds tc Improves Neemn,and who mndracts (¢ouch p(ojem with a
cQn1[Iame0mtuner antSce.othe ContnctarsLianas Lw. BACK PLOW PROTECT.DEVICE FEE
OUSUMMARY
OUTSIDE FEES LJ I ion ezempl order Sec B 6 P C for this mann
Owner Due DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y'_ N
• RECEETI
f� WORKMAN COMPENSATION DECLARATION ]ARES PER TRAP SCHOOL TAX Y N_
Mhereby.meso,tti,t 1 h,we a¢rtific.te a...Im Ku-bus¢,¢.
¢ a or Worken'C¢npewtlonTssuance as¢mti(led copythetm((Sec. RECF]I'1'If
3800,00,1,1�b C.) GAS FA.SYSFFAf-1 WG40VILETS PARK FEE Y_ N_
Co�env WdLSa IIG_ O_ GAS FA.SYS[ OVER4 LEA) BUILDING RECIEIIVISIONFEFS
WCertlficd copy,Is filed Mthrthe ed
city GREASE/INDUSTRL WASTE IN'TFRCFPTOR PLANCHECKFEE
®testes ropy b filed,wth the sty inspection aiwi.i�.
CERTIFICATE OF EXFT4PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATINSURANCE SEWER-SANITARYSHORM EA.3pF1' Date Reoci tp
(ITds,sectbn need not be<omplated B difthelbs permit b f¢os hundred doBue
(f109)¢fWATER HEATER W/VETT'/EIECrR ENERGY FEE Y— N
I¢rtifythyth at lothe per(omun¢of thew¢kfor which this pemWis,issued, _
I shall net employ any person In any Brunner an as to become subject to the WATER SYSTEM/TRFATHNG
Wmkens'Compenaallonlaw,.of GOfomla.Date PAID
C• = ApplicantNEWR®DENTIALPLMIL SQF(.' Date Recti tit
Z O NOTICE TO APPLICANT:It,after nuking this,Certifl¢te of Exempptt con,you
N should become subject to the Wahero'CompesaUan pmovNbsofthe labor TOTAL:
Codeywrustforthwtthcomplywitheachpe losorthiaperosisshallbe
W > deema l.1sed. IN '
CONSTRUCTION LINDU:G AGENCY
CL o SEISMIC FEE
I hereby afRrm t)ut there b a mmtmnbn tenting agennccyy far nese penam. ELECTRIC FEE
Z anceofthe work forwhich this permh is,huel(Sec 3097,CW.C.) TOTAL QQt
fJ O L.codcro Name PLUMBING FEE O O
LL — Lcrder'e Addmae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O LU 1¢rtifythat l have read thisappBatlonand state thatthe abovems
lnforclan
Q. Isco eel.I ogewto comply with all dry and county ordinances and state Lacs PERMIT ISSUANCE FEES PAID:
relating to building construction,and)ereby.whodre representative of thk
F Z city to enter upon the abova mentbrud property for inspection puoses. ALTERORADDTOMECH. Date Recei tM
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino
,,abut liabilities,,judgments,mete and e.penae which may In anyw.y..c AIR HANDLING UNIT(TO 10,OD0 CFM) SUBTOTAL:
agalst said City b cosaque. thegrardbgofthis pemW.
AIR HANDLING UNT(OVER 10,MCFM) CONSTRUCTION TAX
SgratureofAppliumt/Coftractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAMILMOUSMATUIALSDISC10SURE
Will theappllant¢future bulldingomupam.toreor handle h...rd.s HEATING UNIT(rO 100,000 BTU) .
materialDate Recei SN
as defined by the Cupertino Municipal Cade,Chapter 9.1Z and the
Elealthaed SafetyCade Scsfl.25533(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
AL: Q�
❑Ye No
Will the appBnt¢ tore bu0ding occupant use equipment VENTILATION FAN RESIT)) ISSI"ATE
which emit huardcus an contaminants n defined by the Bey Are Alr !-
QualXy Management Dbtrict7 BOHLER-cUMP PHP OR 10gIXA BTU))
Yn ❑No p k
have read the havrdoue mateHais requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU) JUN Qi
tha California Health&Safety Code,Sections 75505,75533 and 75534.I
uedcntand that if the Wilding does not currently have a tenant,that It b my NEW RESIDENTIAL MECH, SQ.Fr
responsibility to ready the occupant of the requirements which mut be met .•.s.s.�I
prierta isuaae of.CertiBateaf pa My. - City Of as�Up@&A
6575= ^'U-,F'�
Owners autharlud agent Date TOTAL ISSUEDBY: JO P—' �WC(
�
OFFICE COPY S,