19929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: \u/
,
I D I C7 O /'S�Q 2 19929
� nancre ame: n 1 Phone; A
oc;z.0t Pc
.�. ACf' c.•, 25r.;4Q CITY OF CUPERTINO�BUILDINGDIVISION �^e1LC)
cen{rQ rarreeS S S K "'D LSS' APPLICATION /PERMIT
—"-1
Archltet/Engineer. Lk.No: UI
BLDINGM
ELECnUCA4PLUMBING.MECHACAL CATEGORY CONTROL Y 5"11;W
CITY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreoa: PERMITISSUANCE OO ❑ El
CONTRACTOR'S DECLARATION
I hereectionl)thanaivBon3oftheunder pemando(chapter9(mmmmc- MPLIANCESRIS7DENML JOB DESC O
ficen h5et1on70(0)of Dlvlgon3o(she BugnessandlarofeselonaCode,and my \ IFMV
license lain full end effect i. PANES w�w,
LicanData Clsss Lk:p �Z45 `
Dale L Contract
ARCHITE CLARATION 00 AMP"'
q�q�uu 0 O I understand my plans shag be used as public recoNOVER
a OVER 7000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fi b E Licensed Professional SIGNS ELECTRICAL
«<< 4ILXv OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C
t., a Ihercbyaffi.that lamexempt fromthe Contractors License LAW for the
oo qqq following reason.($anion 7071.5,Business and Professions Code:An tl or
FZ^ cwntywhkhrequlmapermlttocorutmci,alter,lmprrwe,de=llsh,ormpalr TEMP'METER ORPOLE INST.
g'y anystrutlum priorto itsIssuance,also requireslhe applianHur such permit to
F] Ole a signed statement that he ls licensed pursuant to the provisions of the POWER DEVICES
3 w0 Contramor'e License Law(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC
skm3ufthe Business and Pmfessloru Code)mthat he is exempt therefromand VALUA7]Q7'y
S the basis for the alleged exemption. Any violation of Section 70715 by any
CA applicant fora permit subjects the applicant to a civil penalty of no momthan OUTLETS-SWITCHES-FIXTURES
$ five 1,asunded owner of theS00). NEW RESIDENTIAL ELECTR SQFf. STORIES TYPE CONSTRUCTION
�n m I,as owner of the property,or my employees with wages r smile sale
compensation,wBldotheworbandthestrudurels not intended License Law
[� 93 sale(See 7614,to ainow and Professions Code The or Imptwa hamon Law `tel
$$ does whodotapply chw.rn imaero(proogh hisanemorlmprowas ovided that
tand OCG GROUP RES.UNITS
C: whodoeasuchwork himselforthrough hieawnemployeea,provided thatmch
Improvements are not intended oroffered forok.If,howevep thebullding or TOTAL: LC"
Improvement issold within one yearofcomplelion,the owner-bullderwlll have
14LIfunlen of proving that he did not bund or Improve for purpose ofsals.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contract.to construct the praje t(Sec al
7614,Bunessami I'mfosions Code:
The Contractor's Licence Law does net apply to an owner of property who ALTER-DRAIN k VENT•WATER[EA)
Wild.or Improves thereon,and who contracts for such pTojets with a
cgnt�amu(s)licensed pursuant to the Contmtor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B k P C for this reason
Owner pate DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y 'N
WORKMANRECEIPT a COMPENSATION DECLARATION pp(�gpg PER TRAP SCIiOpL TAX Y N
QI hereby affirm that I have• lmktooe of concent to opythrom,ora RECEIPT Y
3800,remilab of Workers'Comperuallan Wurancearacertl(led ropytherro((Sec. GAS EA.SYSTEM-I INCA OLTILEIB PARK FEE Y N
3o is Tab C.)
Policy Y RECEGAS EA.SYSTEM-OVER 4(EA) DING Df N
Co�mfany BUILDING DI VISION Ff.ES
u CertlOM copy is hereby furnished. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
Certified copy is filed with the city inspection division. �-f,
CERTiFICATEOFEXEMPTION FROMWORKERS' GREASE TRAP PAIDI'I'� ^�y
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Remi HI z_k1
(0).rl ionneed nt Wcomplied lithe permit lsforone hundred dollars
(S]IID)orly that
WATER HEATER W/VENT/E.EOTR ENERGYFEE Y N
]certify thatlnthe person tan [he Weakremm,r so as toh this becemermRls booed,
I shag not employ any person In any manner at u to become abject to the
Data_ WAT.Et SYSI.QA/TRPATING PAID
Workers'Compenutlon Iowa al Ulllomb.
O Z ApplicaNOTICE
Z O NNOTICNEW RESIDENTIAL PLMB. SOFT. Date Remi tq
E TO APPLICANT:If,after nuking this Certificate of Exemption,
Nshould Woumaeubjet to the Workers'Compensation provisions ofthe Labor TOTAL:
N Code,you moat forthwith comply with such provisions orthis permit shall heSg
W > deemed revoked. '
CONSTRUCTION LENOINGAGENCY SEISMIC FTE
d, IherebyafOrm that there is a commrtlon lending agency forthe perform ELECTRIC FEE
7 Z anmoftheworkforwhkhthispermltbbsued(Sec.309'/,Civ.C.) TOTAL:
U O Lender.N.me PLUMBING FEE
LLI- Lender.Addrese QTY. MECHANICAL PERMIT FTE MECHANICAL FEE
O 111
UIcertifythatl have read lhisapplicatianar�d stamthAtheabove Information
lscorred,I agree to comply with all city and county ordinance and gate lawn PERMIT ISSUANCE FEES PAID:
�. W reading to building comtrutlon,and hereby authorlu repremntatives of this -
F Z City to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Recel tH
V against liabilities,judgmenls,mks and expenses which may In any way same AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the grant Ing of this permit.
NR HANDONC UNIT(OVER l(LOWCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE .
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO 100,0DO BM Date Recei tM
material as deo ned by the Cupertino Municipal Code,Chapter 9.12,and the �y�
Ileallh and$. cde�Set1on 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: s9 x/
Rill "131 No
ilemt appitcantor umrcbuilding inants as defined
ndby the Ba Area devkes VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit ha enterna air contaminants as defined by the Bay Area Ab
Quality Manq ement Dbtrit7 BOILER-COMP pE1PDR 100,0(q BTU)
4Yea No
haveread the h V...materials requirements under Cha pier 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health A Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building does not correctly have atenanL that it is my NEWRESIDENHALMECH. SQ.FT.
mpomlbs ancon f a Cehe occopant cmer qulrcnenrs whkh moat be rtaT ' ^\
prior to issuance o(a Certi0cate olOm anEy. V
7 zCZ: 6 Qpm
Uv rorgnitrul:agent Dfs
TOTAL: ISSUED BY:
OFFICE COPY