19628 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingPro'ed Identification ../L PERMIT NO.
BuRaing Aaareas: CV lr•/�f% 19628
e I 1.� /ll0 rtti • ti C07,4 S1 E 2 03 0 P /
raI 408/ Phone: A
_VUT�J r!/S�aarJ I�AhK zsss660 CITY OF CUPERTINO-BUILDINGDIVISION —7—
contradweN Lic.No: APPLICATION It PERMIT
BUILDING-ELFCTRICALPLUMBLNGMECHAMCAL CATEGORY CONTROL(;.Dass
ArcMtM/En cur. LI<.No: ��OOy (�
1.0 VER ECt40.Gr " IN QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Aadreu 7/! A/or I F;rsT s <c 4,.x tet!
s PERMIT ISSUANCE ❑ Q ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commene. APPLLANCFS-RFSLDENTIAL JOB DPSCRB'TION
Ingwith Sec1ion7000)of Division3ofthe Busineas u dPro(essionsCode,and my
license is in full fora and effect. PANELS I,/f/1
LlanseClass LLCM I \n��a r e vTrNU�e ,
Date Lic.st or Y��` e
ARCHITBCI'S DECLARATION 201-1000AMPS I I
M 2 1 understand my plans shall be used u public records. OVER 1000 AMPS SQ.FT,FLOOR AREA $/SQ.FT.
° v D a U (00
-
)d �j Licensed!Professional SIGNS ELECTRICAL a
<�¢' OWNBR-BUILDER DECLARATION SPECIAL CIRCUIT/M15C 'all
ao., Z (herebyafflrmthatlamevemptfromthe Comt.dor's Licenael�wforthe /
O Z f following reason.tSMion 70315,Busmen and Professions Code:Any my or TEMP.METER OR POLE] I
county which requiresa permit tocotutruct,alter,Improve,demollsh,orrepalr
Fgfl` 'V anystronure priorto its issuares,also requiresthe applicant forsuch permit to POWER DEVICFS
file a signed statement that he Is licensed pursuant to the provisions of the ryry�� r
�a Contractor'a License Lasw(Chapwc9(conIM
urencingwithSection700())ofEXA. SWIMMING POOL ELE fl VALUATION
O sion3ofthe Businessand Professlom Code)orthathe Lsemmptthemfromard
the basis for the alleged exemption. Any violation of Section 7mi5 by any OUTLE7SSWITCHESFI ES �� aG
applicant Ems permit subjedsthe applicant to a civil penalty of ma moathan
OCj five hundred dollars($500. NEW RESIDENTIAL ELEC FF.
❑I,as owner of the property, SQ' STORIES TYPE CONSTRIIC"PION
p perry,or my employees r theresok
CN< comperoa0on,wBldothe work.and the eCods:Tbnot
Conrad r'orctrueloffered(or
este(Sec apply to alnow and Prooperty Code:The Contractors hemor.law
�$$ does net apply loanowner ofpropertyhisonemorimprovneed that and such — OCGGROIIP RES UMTS
who does such
entsamwork himself edornugh hisowale.If meverthebildingor
improvement avid hindedoroffered ofcomorsale.theh er-buhebuBdln ve TOTAL:
Improvement hsold withinomycarolcompletbn,theowner-bu0derwill love
0( a_rdenofprovingthit he did nabuRdorimproveforpuryweofasle.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
kd-4 as owner of the property,am exclusively contracting with Ilansed PERMIT ISSUANCE
contractors to construct the project(See:7044,Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who
Weds or improve thereon,and who contracts fou such pNFds with s ALS-DRAIN&VENT-WATERMA)
o9japu r(s)ucensd pursuant to the Coatractor's Lima.Law. FEE SUMMARY
BACK FLOW PROTECT.
LJ I am exempt under Sec. B&P C for this mason OUTSIDEFEES
DRAINS FLOOR ROOF,ARCA,COND. SANITARY Y N
Owne�' Dam 72 J RFC=Y
RIGM OMPENSATION DECLA I�lF OI�T�— SPER.�I, SCHOOLTAX Y_ N_
❑I hereby affirm that 1 have a certificate of consent to self-meure,w a RECELF r Y
LerOficate of Workers Compensation Insurance or a unified copy thereof5ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FE Y N
3800,Lab C.) RECEIPT Polity N
Ce
GAS EA.SYSFCM-OVER l(EA) BUILDING DIVISION FEE$
any
mCerified copy Is hereby furnished. GREASE/WDUSIRLWASMEINTERCFPTOR PLANCHECK FEE
F-1Ceniied copy Is filed with le city lrupcellon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei H4
(Thiasedmn need net be completed If the pereca[to furore hundred dollars
($100)or less') WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_ Cly
I certify that In the perforreanuofthe work fn-which this permit is isweL I
1 shall not employ any person In any manner so as to become subject to the WATER 5YS1�/IREAnNG
Workers Compensation laws of Califomia.Date PAID
O Z Applicant NEWRE4DFNTIALPLMB. SQ.FT. Date Remi is
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Worker'ComperwHon provisions of the Labor TOTAL:
~ W Code,you at forthwith comply with such provisions or this permit shall be BUILDING FEE •,,d
LU j deemedcooked.
CONSTRUCTION LENDING AGElxCY SEISMIC FEE _
d Iherebyafflrm thattherc ba romtmctlon lendingogenryforthepenmo TOTAL: ELECTRIC FEE
Z once ofthe work for which this permit N issued(Sec.3097,Civ.C.) PLUMBING FEE
LL O Lener'.Name TY, MECHANICAL PERMIT FEE
LL f Lender'.Address Q MECHANICAL FEE
U ormet. that
agrect comple mad anthais llcitlondcotate that theordina cess information
W IsctingtoagreetocomplywRh alldtyandcouhorturepreeand gate lam PERMIT ISSUANCE FEES PAID: ��� a
I— CL rela0n enterupon the abovdlogandd propeuthorlu rcecionpurpo althla C`)�Iy
FN dtyto Wenteree to the,indemnify an
propehamr Wpe Cit purposes. ALTDt ORADD TO MFOH.
?
(We)agree to saveJudgment,
d kap es which
the In anyayaccrCupertino Date ReOTAL
V against liabilitlea,pdgments,cortsand expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago Inst said City in consequ ens of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reuel tit
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
r frealthard Safety Codrer�s--S�M��ion25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: .�
.❑ Yea UZ,
Will the a ppllcant or bin rc building wtv pant use equipment or devices VENTILATION FAN(SINGLE BESIDE ISPXLSDATE
which cent hamrdous air contaminants as dented by the Bay Area Air W �brl
Quality Management Mind? BOILER-COMP DHPOR 100,000 BTU)yes .T M '1
1 lone ad the hazai�womaterials requirements under Chapter&95 of BORER-COMP(OVER 100,00 BN) t-=-2 j J 1a�v
the California health&Safety Code,Sections 25505,25533 and 25534. I
understand that lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met ``It•f nF rILPOTtin11
pries to issuance old Certltican of Oca panty.
OwneroY as /rued gent _ - i
m 1SSUEDBY: ///1
TOTAL:
OFFICE COPY