19828 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prosect Identification PERMIT NO.
Building Address: ("�O n
(Ol Al, �o S �I Vi o G
wnera am: hone: APPLICATION SUBMI 11 AL DA M
WG6T1F�kF'k'z CITY OF CUPERTINO-BUILDING DIVISION r /
nno-actormNam: Lic.N.: APPLICATION /PERMIT tr-
qn
L BUfLDINGELECTRICALPLUMBINGMECIIAMCAL CATEGORY CONTROLN
Architect/Iagineer. Lic.No:
1 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 1'(i IMITH
5 �l a PERMITISSUANCE
LA ❑ ❑ ❑
L LICENSED CONTRACTOR'S DECRATION
I hereby affinnthat lamlkenmeunderprov6lomof Chaptsr9(comeren APPLIANCES-RESIDENTIAL JOB DhSCKOTTON
ingwilh Section 7000of Division3ofthe Buslnessand ProfessionsCode,and my
Beer.is in full form and effect. PANELS
Lkcnse lass �Lk.p—j VliTr�l I
Date QContnctor
ARCHITECTS ECLARATION 201-1000 AMPS
Q7 Iunderstand my playshaBbe used as public meards. OVERIODOAMPS SQ.b r.FLOOR AREA 5/SQ.IT.
O
zdZ Licensed Professional SIGNSELECTRICAL
< OWNER-BNLDER DECLARATION
I hereby offiunthe lam exempt fromthe Commences License law for the SPECIAL CIRCUIT/MISC
X0 � following reason. 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
county which rcqulrcsa permit roconstruct,alter,Improve,demolish,orespair
anystructure printer,its usuance,alsorequims theapplicant forsuch permit to POWER DEVICES
C 0 file a signed statement that he 6lkemed pursuant to the provisioru of the
�(04 Contractor's Licerue Law(Chapmr9(mmmencingwith Section 7000)of Dwi- SWIMMING POOL ELECTRIC
F�05 sbn3o(the Busi and ProfessiomCode)orthathe6exempttherefmmand VALUATION
Sn the Ws6 for the alleged exemption. Any violation of Section 7031.5 by any 1 OUTLETS-SWITCHES FIXTURFS
applicant fora permit subjectathe applicant to a civil penalty of not more than
five hundred dollars MOD). NEW RESIDENTIAL ELECTR SQ.FT. b
9..' n 1,as owner of the property,or my employees with wages as their sole TYPECONSTRUCTION
pe ion,will do the work,and the structure 6 not Intended or offered for
Osate(Eec.7844 Business and Profesdons Code:The Contractors License Law
�$$ does not apply to an owner of property who builds or improves thereon,and GGROIIP RFS.UNITS
who don such work himself orthwgh his owa employees,provided that such
Improvements are not Intended or offered for sale.If,hoevep the building or TOTAL: �3Q
Improvement 6sold within one yearofcompletion,the owner-builderwill havew
to menof pmmng that he did caw Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
S as owner of the proe perty,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Professions Code:
The Contractors Ltcanme law does not apply to an owner of property who
Wilds or Improves thercoa, and who contracts for such ptojeds with a
�gp�acd pursuant m ens cr,nan
anrm urcnse Law. FEE SUMMARY ALTER-DRAIN&VENT-WATER(EA)
am exempt
LJ I am exempt under Sec. B&P C for this mason BAIX FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION
VjI FDnURES PER TRAP SCHOOL TAX Y_ N_
hereby affirm certificate I have acertificatens
cate of cement m self-insure,ora RECEIPT N
mdificateofWorken'Compevtimlruurance or a ecrtifed mpythearof(SM. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C.) ]RECEIPT N
Policy p GAS EA.SYST[M-OVER 4(FA)
Cam any BUILDING DIVISION FEES
rtlfied ropy 6 herebyfumished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cc 'tied ropy 6 Bled with the city W pectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi t#
(This section need not be completed lithe permit 6 for ore hundred dollars
(S100orless.) WATER HEATER w/VENT/13.ECTR E•NE•RGYFEE Y_ N_
I certifythat in the performance of the work for which this permit Is issue,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers Compensation[novo of California. Date
O Applicant Date Remi t#
2cate NEW RESIDENTIAL PLMB. SQ.IT.
ZO should becETOome
APPLICANT.If, ori mkingth6ation,Pro Offs, fflhogyou
Hshould become mbpctmthe Workers Comperualon prov6lom ofthe Labor � TOTAL:
v) Code,you must forthwith comply with such provisloru orth6 permit shag be BUILDING FE•E
K j deemed revalued.W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il I hereby affirm that hem 6 a mrrttructlon lending agency for the perform TOTAL: ELECTRIC FEE
D Z ance of the work for which this permit 6 issued(Sec.3097,Civ.CJ
V O T.eeers Name PLUMBING FEE
LL f- Tenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW Ireeify that l have read this application and statethatthe above information
1 6correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>- relating tobullding construction,and hereby authorize representatives of this
F— 2 city to upon the abowcmationed property far inspection purposes. ALTIRORADDTOMECH.
_ Date Receipt#
(We)agree tonve,indegiVestexyli
harmlessta inanywyaty of mmeino AIRHANDLING UNIT(O 10,000CFM) SUBTOTAL:
agalmtl6bNties,pdgmen sn whichmayInanywayaccrueagi imt I nn f the rating of this permit.
AIR HANDLING UNIT(OVER 10,000CFM0 CONSTRUCTION TAX
Sig no pp Cant/ m az D(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA OUS MATERIALS DISCLOSUR
Willtheappitcant uture building occupant store or handle hazardous HEATING UNIT(M 100,000 BTU) Date Reuel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
llealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTI)) TOTAL: V7JT�
0 Yes M No
Will the applicant or future building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUAN DATE
which emit haurdous air contaminants as defined by the Bay Area Ale 4AT
• Quality Management District? BOILER-COMP OTIPOR 100,000 BTU)
4 Yes No /7 1'
have read the huar usmteda6requiremn6 under Chapter 6.93 of BOILER-COMP(OVER 1W,000 BTU) IrI�K + ,'tr
the CaBlnrnia Health&Safety Code,Sections 25585,25533 and 75534. I �� I
understand that if the building does net currently have a tenant,that it 6 my NEW RESIDENTIAL MECFL SQ.IT.
responsibility notilyt copant the requirements which most be not — �IIT`0.y
prior to o(a ate of nvpancy. µ,brio
Owner ora D e
TOTAL: ISSUEDBY:
OFFICE COPY