19469 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building P1raen Identification PERMIT NO.
Building Address: ,I_L (D0_&_ VI k a(44 -3)
19469
Name- O Phone:
rte . CITY OF CUPERTINO-BUILDING DIVISION ' f L-11^qio
G n ct 'a�.: �Li No. APPLICATION /PERMIT C
'7— 1
A hitect/ BUILDINGS.ECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL Nrr. a7n
Lk.No: V 7
I `AV QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PPRMITISSUANCE ('X)'
LCF. ED CONTRA TOR'S DECLARATION
I hereby a(firmtha lam lkmeed under provisions olChapter9(commene APPEANCFSRF.SIDEN77AL . JOB DESCRIPTION
11 ..ISection to.a defect. afthe BuMnessand ProfeulonsCode,and my - 1
Ilcensa b In toil!orae and effect. PANELS f�
Llconse Clam LI[.X I/✓)
Date Con[.tlor
ARCHITECTS DECLARATION 201-1000AMM
p sZ I understand my plana shallbe used as public remrda OVER I OOO AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
lG �j Licensed Professional SIGNSELECTRICAL (' 2Z 7'(a Z
Ly
<6 OWNER-BUILDER DECW RATION SPECIALCIRCUIT/MLSC �(/rte �'/ [/ �7
ZF, 1herebyaffirmthat Tam exempt(reenthe Comractots License Lawforthe /6
G g F following reason.(5eMss on 7031.5,Busineand Professions Code:My city or LEI U
county which requmm a permit to conshuct,alter,impreve,demolish,or repair
k.
ryG
anystm=mpriortoiUismance,alsomquimtheappliant(or chpermltto I I G 1 file a signed statement that he is licensed pursuant to the provisions of the l •O
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. iu
athefmandelan3o(the6udneaeand ProfesslorsCode)erthet he VALUATION
the bash
in the alleged exemption. Any violation of Section 7071.5 by any v-s
applicant far.permltmbjecta theappllcant too civil penalty of not morethan OUTLPTSSWITCHFS S
five hundred della.(S50(B.
�n 14
❑I,as owner of the property,or my employees with wages as their sole 51ORIE5 TYPE CONSTRUCTION
compensation,will do the work,and the structure is not Intended or offered for
a uI.(Sec.709d,Bu.lneuand Professions Code:The Cont.ctols License Law
�$ docs not apply to an owner of property who Wilde or Improves thereon,and OCC.GROUP RES.UNITS
who domsuch work himself orthrough Ns own employm,provided that such
Improvements a.nm Intended...Ifered lar ulc.If,h..,,the building car TOTAL:
Improvement issold within one year ofcomplallon,the owner-build erwill have
thLkurden of proving that M did em build or Improve for pu rpose of ule.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
I^contractors to construct the project(See.7044.Budness and Professions Code: L
The Contrictorb License Law does no apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilds or wee thereon, d who contracts for such poaj cta with a
cI (.)R used porn tto he Cmdmd .Lkenuw. FEE SUMMARY
io re
1_J I m e rept un a Sec. B&P for thason BACK FLOW PROTECT.DEVICE
ES
Owner
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Date
WOR O 1 SATION OECWRECEIPT If
KMAN CR O SCI POO TAX[:]I hereby affirm that I have a certificate of consent pD(7TJRp_S PER TRAP Y N to self-Insure,or RECEIPT N
cenlflcate of Workers'Compensation Insurance or a certified copy thereof(Sec. GAS F.A. YSFENd INCA 3800,lab C.) PARK FEE Y_ N
Policy M RECEGAS PA.SYSTEM-OVER 4(EA) DING DI X
C ffCcy BUILDING DIVISION FEES
1 ICenlfied copy Is herebyth the id, GREASE/INDUSTRL WASH INTERCEPTOR PLANCHECK FEE GCG g
rL�-JCcnlOed copy b filed with the city Impenlan division. o a o
CERTIFICATE OF EXEM PEION FROM WOR K ERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlsucilooneed net becompleled lithe permit bforone hundreddollan SEWER SANPTARY STORM EA.203FT. Date Receipt#
(s100)orlcnJ WATER THEATER W/VENT/ELECTR ENERGY FEE Y N
(certify thatInthe person inaofthework for permit I.
I shall not employ any tenon in any manner ea ss to become subject to the WATER SYSTPM/TRRA7TNG PAID
Woplica Compenution Gwa o(Callfomla.Data
O Z NOnCE° Date Recel t#
Z O NOTICE TO APPLICANT. makingthis Certificate of Exemption,you NEW RES[DFN77AL PLMB. SQ.Ff.
H should become subject to the Workers Campeuellon proWlons of the Labor TOTAL:
a. W Code,you most fort hwlth comply with such provisions or this permit shall be p
> deemed revoked. BUILDING FEE I'
dC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyeffirm that there is a construction Lending agency for the perform C ELECTRIC FEE
0 Z anceafthe work(orwhich this pemdt lau
hued(Sec.3097,CIv.C.) TOTAL: IDOsS 170a�
V O I<nder.Name PLUMBING FEE f)OaS�j
LL'H Lendce.Addnaa QTY. MECHANICAL PERMIT FEE 00
O W I conilythat l have mad thlaappliaMECHANICAL FEE
tionand statethatthe above Information �'I 1035
C bcorrect.I agree to comply with all cityand county ordinances and Mate laws PERMITISSUANCE {.M FEES PAID:
} relating to building construction,and hembyaathorlaerepreeentativaofthis
W
(— U) city to enter upon the aWv rnrrtfoaed property for Inspection purposes. ALTERORADDTOMECH. Date R('.Cel t#
z e gree to uve,In ly an d keep hamdem the City of Cupertino p
e Inst abllitIm,' dgme e, Band expenses which may any ayaccrue AIRPUNDENC UNIT Q010,000 CPM) SUBTOTAL:
a aloe void Cltyl aqu of the granting of this pe IL AIR HANDLING UNIT IO,000CFM) CONSTRUCTION TAX
L)Sig reof Appllcant/Contr or EXHAUS'(HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2!ARD00P MATERIALS DISCLOSU E
Will the appllant or future building occupant store or handichaaardous HEATING UNIT(TO 100,"BTU)
material as defined by the Cupertino Municipal Code,Chapter 9,1 2,and the Date Recel t#
HealthanciSafetyCade Sedton25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL03Sa
❑ Yn []No ••
Will theappliant or iuNmbuildingompant ussegWpment mdevicea VEMIWTION FAN(SINCLE RFSID) ISSUANCE DATE
which amlt haaardous air contarromen as de0ned by the Bay Area Air
•� Qu IIIy Mawgermat District? BOILER-COMP 100,0(10 BTU)
4Yea �''�No
h ave read thehau�ouartate avrequlrcmenMunderChaper895of BOILER-COMP(OVIR100,00)BR " �ry�
the California Health&Safety Code,Sections 25505,25533 and 255: .1
understand that if the building does not mrrcntly have.tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr. APR 'f9tlt•T
responsibility to notify the occupant of the requirements which moat be met J V
prior to issuance of a Certificate of Ocmparay.
Owner or aul horiad agent Date ISSUED 6Y
TOTAL: OOI
OFFICE COPY