19390 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
BnRd/o;� k/ Glou�f �� 19390
aroName: t Phone: q AL UA IL
CITY OF CUPERTINO-BUILDINGDIVISION
• COntractor'sName: ut.No: APPLICATION /PERMIT U
/NO/Q56 r_o..ast4ur_tia Sha/7.�� BUILDINGELECTRICAL-PLUMBINGMECTIAMCAL CATEGORY
Am /Engineer Lk.No: (OY
�E. ,pN rrE'Z
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO
Address:
LICENSED CONTRDECLARATION
PERMITISSUANCE L�O
1:1
1:1
❑
Ihereidifirmi that mdunderprovisions ofChapmr9c APPllANCESAFSIDEMIAL JOB DESCRIPTION
ingwlthScvtion7000)ofDwision 3oftheBusinassandPro(essionaCoideand m
Iknsbiifullf d affect, rn7
LiceCh® SbqLIc.N 7S ( 141OC27 Co 64�.(
Data
Contractor UP TO 200ANIPS
ARCHITECTS DECLARATION 201-i"AMPS
XZ I understand my place shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
L., a Iherebyatfirm that l son exempt from the Contractor's License Law for the
F,^ following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE
u� countywhich requinsa permit to construct,alter,improve,demolbh,orrepalr
anysuucture prlorto its issuance,also requiresthe applicant for such permltto POWERf EVICES
'S O V file a signed statement that he is licensed pursuant to the provisioce of the /
�3uG Contractor's License Law(Chapter 9(commencing with Section 7000).(DEW. SWIMMING POO C VALUATION
O< sion3ofthe Businemand Prcde WmCWe)orthathebexem themfmmand
p S2^I the basis for the alleged exemption. Any violation of Stiction 7031.5 by any OUTLETS / O 00
„FqJ ¢On applicant hers permit subjects the applicant to a civil penalty of not more than
$i five hundred dollars,($500). NE R STORIES TYPECONSIRUCTION
I,as owner of the Property,or my employees with wage as their sole
�7� compensation,w111doNe work andthenrodure boot intended cur offeredfor
��O sale(Sec.7044,Business and Professioce Code:The Corvranofs Licerue Law
5$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RIS.UNITS
who don such work himself or through hisown employees,provided that such
improvements are not Intended orottered for sale.If,however thebuildleg or TOTAL:
Improvement b sold within oayearofcnmpletion,the owner-bulkier will have
t"iden of proving that he did raft build or Improve for Purpose of sok.). QTY.I PLUMBING PERMIT FEE FLOODZOI APN
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the proyet(Sec.7054,Business and Professions Code:
The Contractors License taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
WiM.or Improv.thereon, and who contracts for such pEepets with a FEE SUMMARY
0gnt[adons)licensed punuanttothe Comractor'sLicense Law. BACK FLOW PROTECT.DEVICE
LJ[am exempt under Sce. B &P C for this mines
DRAINS FLOOR AREA,ROOF,ARGOND. SANITARY Y N
O
• av^ef mance DEC RFxPI'N
WORKMAN COMPENSATION DECLARATION
F11 hereby affirm that I have•cenifirate of consentInmreFIXTURES PER TRAP SCHOOL TAX Y N
to self- ,or RFGEIFT N
cedltldda.f Wmkers'Cmmpeaation Wu codified copy thereef(Sec. GAS F.A.SYSPEM-1 INCA OUTLETS PARK FEE Y N
3800,lab G RECEIPT M
Polley NGAS FA.SYSI'FM-0VER d(FA) BUILDING DI V ISION FEES
Com
ECeraynified copy is hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Comfled copy Is filed with the city inspection division.
CERTIFICATE OF F.XEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WFT Date Remi t#
(Thissection need not be completed tithe permit isforone hundred dollars
(S100)or less.) WATER HFATM W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhich this permit is issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worlui Compensation laws of California. Date PAID
O Z Applicant NEW AESID[NTIAL PLMB. SQFT. Date Remi t#
Z O re provisions
APPLICANT:If,after making this Certificate of Exemption,you
HN should bemisubject to the Workers Compensation prolons ofthe Labor TOTAL:
CC Code,you must forthwith comply with such provisions or this permit shall W BUILDING FEE
LU _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE .2
CL Ihereby affirm that there Is a construction lending agency for the perform, ELECTRIC FEE
Z ante ofthe work for which this permit is Issued(Sec.3097,Civ.Q TOTAL:
U O Lenders Name PLUMBING FEE
LL F I.endcr'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Imdllythatl have readthisapplicatlonand statethat theabove information
O W is contra.l agree tocomply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. (L relating to building construction,and hereby authodam reprnentativea of this
(_ N city to enterupon the above-rremtioned property for Inspection purposes. ALTEiORADDTOMFGH.
2 (We)agree to save,Indemnify an d keep harmless the City,of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may in anywayaccrus AIR HANDLING UNIT GO I(Lf(K)CFM) SUBTOTAL:
ar!
gal�t said City .�en of the rating Of this permit.
AIR HANDLING UNIT(OVER 10,00nCFM) CONSTRUCTION TAX
Signature o(Appl ant/Contractor Date IXFSAIIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futurt building occupant store or handle hazardous HEATING UNIT(TO 100,010 BTU) Date Recei t#
materialasciefineibythe Cu lino Municipal CvxJr Chapwr9.12,andthe
HeaOhand SafctyC a on 26532(a)7 HrATINGUMT(OVER100,0008'M TOTAL:
❑ Yes No
Wllktheapplicant r tum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) SSU_KNCE DATE
which emit lurardous air contaminants as defined by the Bay Area Air
Quality Maag tDb 7 BOILER-COMP pFR'DRIOO,tsq BTU) - '
Ycs No -90
4havt rad
the ous materials requirements under Chapter 6.95 of BOR.FR-COMP(OVER I W,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building docs not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT.
raponsibilitytondilytheoccupantofthemqul .t,whkhmustbeenct '� °/r14at IId
priontobsuseced rtifkatoof0 rp
B'rS-9d
Owner or authorizA agent Date TOTAL: ISSUED BY: �1`-'r✓ s N"`��"`^'L,
OFFICE COPY /