19921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
Building Address: 19921 n V92/�a�
22 / 03— k-41L/gt 1P �� t 1Ca'iOPitT.4w'O a9J
Owner.Name: 732-725"1 Phone:
�011/y-y IS�P�' of 7Tz-7a-P CITY OF CUPERTINO-BUILDING DIVISION �1
ears creAsName: f Lie.N.: APPLICATION / PERMIT J — '10"QO
HMLDINGELECTRICAL.PLUMBINGMECHAMCAl CATFFARV CONTROL N)YJf
# ZoAf-kA Mrect/Eeglncer. Lic.N. - L
C QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 7265 7_ Co2r✓wryas�o / , faS PERMITISSUANCE
LICENSEDCONTRACfOR'SDECLARATION
(hereby aftbmthallam Bcemed under provWonsof Chapter9(comment. APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000).1 DieB1.3 ofthe Buslneamed ProfesslonaCode,and my
Ilnnse In In fun force and effect. PANELS
License Cha Lk.Y
Date Contractor UP TO 2DOAMPS
201-7000AMM 1 rC r 1�.�•f� �� C.J�J
ARCHITECTS DECLARATION
Io�00 Zp Iundentand try plans shall be used apublic records. OVER 1000 AMPS ' SQ.FT.FLOOR AREA S/SQ.Ff.
E Licensed Professional SIGNSELECTRICAL /'\ 01
<I-n OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MISC
y, Iherebya(firnthallam exemptfromthe Contractor's License Lew for the
Z 0... following reason.(Section 7071.5,Business and Professl.ru Code:Any city or }�
'OZI. TEMP.MEHR OR POLE(NST. (TJJ
county cture primrecletoss permit to consisted,alter, aplica demolish,ormit ir
to
F� anyetroclure prior to lb iswance,alsorequirnlheappBram for such permit to POWERDWCES
Gµ7 file A signed statement that he is licensed pursuant to the Provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SW1brAPNG Pool, ` C
6 f„�OJ Alen 3 atthe Business and PrefesebruCc A)mthat he is exempt therefromand - VALUATION..•7777 the basis for the alleged exemption. Any violation of Section 70315 by any /
applicanl(ora permi[sabjeM the applicant lea ciWl perulty of na[more than '• V AeV't6 s c"'
OOO five hundred doll..(5500). NEW A EL .Fr'. SfORI TYPE CONSTRUCTION
ME,as owner of the property,or my employees with wages as their sole
< compensation,will do the work,end the structure is not intended or offered for p ,(
❑ Ask(Sce.70K Business and Professl.tu Code:The Contractors License Law t
SR does not apply to an owner of property who builds or improves,thereon,and 1, E OCC.GROUP RES.UNITS
who doesauch work Mm elforthrough his own employees,provided that such
improvementsam not Intended oraftered forale.If,however,the buildings 70TAL: 0
Improvement is cold within oneyearo(complMlon,the owner-builder cacti have
(Murder,ofpmving that he did not build m improve for purpose ofsale.). QTY. PLUMBING OERMIT FEE FLOOD LONE APN
Lj 4 as owner of the property,am exclusively contracting with licensed
contractors to coralruct the project(Sec.7064,Business and Profealoru Code: PERMIT ISSUANCE
The Contractors License Law don not apply to An owner of property who
builds or Improves thereon,and who contracts for such pt.kcts with a ALTER-DRAIN kVENT-WATER(EA) FEE SUMMARY
o7alpetorWlicensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LJ I am exempt under Sec B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. pp SANITARY Y N
Owner Date a1 C? V^�O RECEIPT
WORf(ItAN JSATTON DECLARATION S�.TI� SCI100L TAX Y N
❑I hereby arm I have am
that have a rtlfieale of consent IXEL ,
nl Belt-Insure,or RECEIPT M
ccrlliMC(W.rken'Comperwtlonituunnce ore¢rtlfled copy thereof(Sen CAS.EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
(Policy Y "/ II N
Cam any P.A.BYBTFT7-0OVER BUILDING
NG DDIVISION FEES
cn
Certlfied copy ishereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCI-IECK FEE
Certified copy is filed with the city inspection dlvblo��
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP PAIDSAJry-B
COMPENSATION INSURANCE SEWER-SANITARY-SIDRM EA 200Ff Date Recei 171
(fhisaectkm.AAdn.t becompleted lflhe permit L forormhundred dollen F _
(S100)orlessd WATER L3FATLR w/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance.(the work forwhlch this permit is issued,
I shall not employ any person In any manner at a to become sub JM to the WATER SYSTEM/TREATING
Workeni Compensation Laws of Cnymanner At, (J PAID Q
0 Z Applicant NEW RESIDENTIAL PI,MB, SQFT. Date ReCel t71 ( oc,
21
Z D N0210E TO APPLICANT.I,after making this Certificate of Exemption,you
should become subject to the Worker'Compensation provisions of the Labor TOTAL:
(q
Code,you=at forthwith comply with such provisions or this permit shall be BUILDING -O
W deemed revoked.
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I bereby affirm that there is a cooahuctlon lending agency for the perform- ELECTRIC FEE
Z ance of the workfor which this permit Is issued(Sec.3097,Civ.C.) TOTAL: ,O�
V O Lxrdee.Name PLUMBING FEEp
F Lenderapddma QTY. MECHANICAL PERMIT •E D
LL MECHANICAL FEE
O W emot.Ithat I agreet cready with
alkatlana Ad dcounte that the yordinancesegatelaInformation
a Iecoingtobilding complywo ,allcityharebcouhorom ordinances and gate PERMIT ISSUANCE Z. /f PEES('AID:
rela} N city to gtabupon t mmbActenceenddproprtyorlupetionnpurpos ofthis
cityW)aree to ave,he Inve-mentlonit property harmless
Cit purposes. I ALTER ORADD'f(3 MECH.
? (We)agree to Rave indemnify an d keep harmiea the City of Cupertino Date RCtic
V
Against liabilities,judgments,judgments,coctaend expenm which may Nanywayacenae AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
' Aift HANDLING UNY ryinfI0,000c• CONSTRUCTION TAX
Signature of Applicant/Contractor Data ID(HAUSTNOQD(W CONSTRUCTION TAX PAID:
HA2 R DOUS MATER IALS DISCLOSURE ft
Will the applim At orfuture building occupant store or ha Ad le havardous HEATING UNIT(TO BTU) O Date ReceI t#
material as defined by the Cupertino Municlpai Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes u No
Willtheappllcantorfunumbuilding occupant use equipment ordevlon VFNTILAIONFAN(SINGL.BESIDE ISOM DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,IX0 BTU)
Yesn❑No
have mad the hazardous materials requirements under Chapter 695 of BOILER-COMP(OVER100,000IT'Ll JUN 1 1990
the California Health k Safety Code,Sections 25505,25533 and 25534. 1
understand that lithe building does not cmmntly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.IT.
respmalbility to notify the occupant of the requirements which at be not City of Cupertino
prior to Issuance of a Certificate of Occupancy.
Owncrm.iithorlred agent Date /• �,/c
TOTAL: •OO ISSUEDBY:
OFFICE COPY