19930 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuDd
o�t3ddess. Jam �asKlo��ye CYEu� 19930
rs ante: a Pone: p
CITY OFCUPERTINO-BUILDING DIVISION
ca rado eName: Lie.Na: APPLICATION /PERMIT l
O G$G (p JS7XKGT70n/ T+t/C S-6 73 BUILDINGELECTIUCALPLUMBING-MECHANICAL CATEGORY CONTROL N�J1
Amhited/Engineer. LIB No: PA
I G
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S CURATIOIQ
Ihcrebyalirn that l am ficensed under provisions ofChapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section 700)of Dlvision3ofthe Businessand PmfesslonsCode,and my
lirense Is In fullf and died, PANELS
Llrense�6ss= LicN .J��7SI 'rix1�I'x
Dat Contactor L �I�U�J\ Fn
ARCHITECT'S DECLARATION 201-1000 AMPS
ggq�u ot07C I understand my plans shallbe used as pubbcrecords. OVERI030AMPS SQ.Fr.rL ABPA $/SQ.FT.
Li
a tj censed Professional
< SIGNS ELECTRICAL (PjP)a
�G
OWNER-BUILDER DECLARATION IRCIRT/MIST �1,
IherebyafRrtnlhat l am exempt from the Contractor'a Limn wfnethe
DO following reason.(Section 7015,Business and Professions Cod : ny city or P,ME!'ER OR POLE INST.
'ZZ countywhkhrequiessapernottomratrod At eq improve,demo ,orrepair
anystructurepriortoitsissuance,also requiresthe ap n chperrdt toppWER DEVICES
d ZP
file a signed statement that he Is llmnsed pursuant t t revisions o e
Owl Contractor's License Law(Chapter 9(command Ith Sedlon vi- SWIMMING POOL ELECTRIC VALUATION
30 slon3ofthe Rusinasand Professlo Code) hebexempt th mmand
0 g the basis for the alleged exemplio . n vlolation of Sectio 7 S by any OUTLETS-SWITCHES-FIXTURES
RES
O C
a ppliantf.r.parMtaubjAclaths anttoovilpenaltyo otmorethan �Q 000
five hundred doth.IS.SOO. J W ESIDENHAL ELECTR SQ.FT. STOW TYPE CONSTRUCTION'
�1,as owner of the properly,o egtyl6yses with wages their sole
�7Q worpensation,wllldothework andthas re6nothuststed iff$++��for
9 ❑ sale(Sec.7614,Business and Professions Code:The Contr dol IceTiA
5$ docs not apply to an owner aproperty who Wilds orlm( cave theme111Ind OCC.GROUP RFS.UNITS
who does such work himselforthruugh his own employees" ided that such
improvements are not Intended oroffered for sale.ILhowe p he Wilding« TOTAL:
improvement bsold within one yearof completion,the owner-b Ilderwllihave
t11t�aniers of proving that he did nal Wild or Improve fee purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to corstrod the project(See.70K Business and Professions Cnde:
The Contractor's License Law does not apply to an owner of property who
Wild.or Rmprovei thereon, and who contracts for such p�ojeds with a ALTER-DRAIN&VEM-WATERIEA)
cl5ador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEITN
WORKMAN COMPENSATION DECLARATION �.rU��.�P SCHOOLTAK Y_ N_
❑1 hereby affirm that 1 have o l rt.,.to of covens to opy thsu.,ora RECEIPT M
3800,abo(Worke.'Compensatton WuranceoracertifMd copythereo((S«. GAS EA.SYSTEM-]WCAOUTLEPS PARK FEE Y N
380.Lab C.) RECEIPT a
Policy N GAS FA.SYSITM-OVER 6(FA)
Cam any BUILDING DIVISION FEES�
Certited copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F-lCertiRed copy 6 filed with the city Inspection division.
CERTIFICATE OF O(kWPT]ON FROM WORKERS' GREASE TRAP 1c
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200E 1'. Dale Recei 1# -1�` aL` +
phis section need not W eomplcteel if the permit 6 forov hundred dollars
($10)orlcss.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
I certifythat In the pedormanre of the work for which this permit is Issued,
I shall not employ any person In any manner An As to become subject to the WATER SYSTEM/TREATING _
Worke.'Compensation Laws of California Date PAID 'e
OZ Applicant NEW RESIDENTIAL PLMB. �.FT. Date Recef W
t# GOs
Z O NOTICE TO APPLICANT:I,aher making this Certificate of Exemption,you
Hshould become d subject to the WorkeCompevation provisions of the Labor TOTAL:
CC N Code,you most fort hwith comply with such provisions or this permit shall be BUILDING
> O' la3
LU deemed revokSEISMIC FEE
ed.
CONSTRUCTION LENDING AGENCY
CL _ Ihembyafflrmthat there 6acovtroction iendingagency forthe performELECTRIC FEE
M Z an.of work which this permit 6 Luued(Sec.3097,Civ.C.) TOTAL:
U O Lanaer.N,mc PLUMBING FEE
LL F Lendera Addrea, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
l certilythat R have read thisappRationami state thattheabove information
O 6c
W orred.Lagree to complywith all city and county ordinances and state laws PERMITIR3IANCE FEES PAID:
0 relatingtoWildhgrorotmHon,and herebyauthorizerepresentativeso!this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDIOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,was and expenses which may In anywayacerue AIR HANDLING UNIT(70 10,000 CFM) SUBTOTAL: _
Against said City Rn consa u,sceof the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOCOfW/DL1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CFO 10,0(1 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1;and the
I kalth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 10(700 BTU) TOTAL: L
Yes MNo
Will the applkant or future bW Iding occupant use equipment or devim VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air contartlnanU as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 10,000 BTU) 4 MAID
4Ya az � No
havereadthehaIIrr2usmaterials requirements useer Cha peer 6.95of BOILER-COMP(OVER 10,000 BT U)
r , the California Health k Safety Code,Sections 25505,5533 and 25534. R (1�y
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. 'Q.FII tNl
ENIII k7
responsibility to notify the occupant of the requirements which must be and
pZ/
to muanre of Certificate f0ccupanry.
Zne '
A. j 190 . tis Of Q 'Cl!V�aWi
a'uthoriud agent Date TOTAL: ISSUED BY YO
OFFICE COPY