19737 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PEILMT NO.
Building Address: - 19737
4 `ners of/: phone: CITY OFCUPERTINO-BUILDING DIVISION1 A
comrador'a Name: ue No: APPLICATION /PERMIT 2 ^24 ?D
_ L I SUfLDINGELECTRICAL.PLUMBINGMECIIANTCAL CATEGORY CONTROL X
rchitea/Engineer. Lk.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 10< ' 21� �( PERhIITISSUANCE �,Z� ❑ ❑ ❑
6 LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l am licensed under provisions of Chapter9(comment. APPLIANCESRESIDENTAL JOB DESCRIPTION
ingwhh Sedion7000)of Division3ofthe Busimmand ProfesslonsCode,and my
license Is In full force and effeet. PANELS
License Cl �, Lk.X� tri
Date, Contractor, �/VT% n
ARCHITECTS DE RATION 201-1000 AMPS
a0U 2 I understand my plans g b
shae used as public records. OVER 1000 AMPS / SQ.FT.FLOOR AREA $/SQ.FT.
u�O Licensed Professional (USIGNS ELECTRICAL CL M
�j
<� OWNER-BUILDER DECLARATION //�
fn eFn I SPECIAL CIRCIRT/MISC aloo
o Iwing of@mthatlamexem lroessa Contractor's License Law fort he
�Z
following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR PO ST.
I'u9 countywhich reques a permit toconstruct,alter,Improve,demolish,ormpur
any atructurepd rtolt.Le ..a ,abarequireatheappU.tforsuchper tto POWkR
file a signed statement that he t.licensed pursuant to the provisions of the DEVICES
Contractor's License Law(Chapwr 9(commencing with Section 7000)of Divi- SWPQ CPOWC VALUATION
� O sion3otthe Bur tsinessand Prefemiom Code)orthathet.emm therefmmand _
the bast.fohe alleged exemptlon. Any violation of Scalon 7MIS by any 00UrrLET, ES
!yA applicant fora permit subjectsthe applicant to a dvil penalty ane morethan J
live hundred dollars($500). WR ENTIAELEC SQ.FT. STORIES TYPECONSItUCTION
.. ❑I,as owner of the property,or my employees with wages as their sole
C7< compensation,willdothewor"Adthestrurnrrvissm Ntendd or of or
y D sole(Sec 7144,Business and Professions Code:The Contractors License Law
�s$ docs not apply to an owner of property who builds or Improves thereon,and OCC.CROU13 RF.S.UNITS
whodcessuchworkhlmselforthwghhis wnemployees,provlddthatsuch ('Y
Improvemenbam not intended oroffemd(a( or mle.If,however,thebullding a TOTAL: r'�l
Improvement lssold withinoneyearcompletion,the Owner-builderwill have �
tryW.k+aces otproving that he did not build orimprove for purpose o(eak3. QTY. PLI GPE MIT PEE FLOOD ZONE APN
UL as owner of the property,am«elusively contracting with licensedjPtpQLMITISSUANCE
contractors to consumer the project(Sec.70K Business and Professions Code:
The Contractors License Law aces rat apply to an owner of property who
Wilds or Improves thereon,and who contracts for such pto)eds with a ALTER-DRAIN&VENT-WATER(EA)
cgB}fador(s)licensed pursuant to the Contrador'.Lkense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L,J 1 am eumpt under See B&P C for this mason
DRAINS R FLOOROOF,AREA,COND. SANITARY Y_ N_
Owner Data RECFZ['1'X
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCI100L TA% Y_ N_
❑I hereby affirm that I have a certificate of consent to u1(-invm,ora RECEIPT M
cedfficate a workers Compenutlon Insurance ora certified cepytherem(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE YN
3800,lab C.) _ —
RECFL'T X
Pollry M GAS EA.SYSTEM-OVER 4 BIA)
Com any BUILDING DIVISION FEES
Ified copy t.hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy Is filed with the city Inspeed..division.
CERTIFICATE OF E( MPFLON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2001cr. Date Recei t#
GhlesMlon need na W completed lithe permit is forone hundred dollars
(SI0()orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the pedormanmof the work for which this permit is Issued,
I shall not employ any person in any manner so m to become subjed to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SRT. Date Recel t#
Z O N'OTICETO API'LICANT:R,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation proWlom oHhe Labor TOTAL:
2 W Cdgyoumustfoehwithwmplywithmchprovt.iomnrtht.permitshailbe BUILDING
W d re
> deennvoked. -
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that them is a construction lending agency for the perform- TOTAL: ELECTRIC FEF.
Z an.athe work for which this permit is issued(See.3097,CIv.C.) PLUMBING FEE
(,) O Iudere Name
LL F Lenderswddmsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certifythat l have read thisappllcatlonand state that theabove information
O W Ismrmd.I agreeto comply with all cityand countyodlnances and sate laws PERMUISSUANCE FEES PAID:
> 1 relating to building conswction,and hereby authodu representatives olthis
to city to enter upon the above�mcntiond property for lmpedion purposes. ALMORADDTOMBCH.
Me)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future,building occupant store or handle hazardous HEATING UNIT(TO 100,W)BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Ikalth and Safety Code$Mion 255320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: s�
❑Yes n No
Willtheapplicmt or futurebuildingoccopantuseequlperent ordevices VENILATIONFAN(SINGLERESID) ISSUA RATE
which emit hamnims air contaminants as defined by the Bay Arca Air 4
Quality Ma regement District? BOILER-COMP OTB'OR 100,000 BTW Aha
Y�
4Ym ❑❑No ! G a Fj
havenla tealth&rdons materials mquimments 255525533rChapte . I of BOILER-COMP(OVRIZIW,OOD BTU) rr1 7T)(T0
theeralfornlaat if to f! Code, umen 0havea3rantthY1. I JJ
understand that if the building Curran mens. hichL that it met NEW RESIDENTIAL MECH. SQ.FT. a� g
raponsibllltyton hece pa of the irements which nasi be nret w
priori ane of rtifi
Ow ro u orizeda Date ISSUT:DBY�?e
TOTAL:
OFFICE COPY