19590 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE`BALL POINT PEN ONLY
building Pmnccl Identification - - - PERMITNO.
Building Address: - 19590
_71X n re �7e: A
- /ShQ'G/L/p per/ CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: see No: - APPLICATION'/ PERMIT
A hitect/En n r. BMLDING-D.ECTRICALPLUMBINC-MME MCAL, CATEGORY CO IaA'�3
gi a Lie Na 77
CITY ;1ELECTRIC PERMITIj1 '1-1,FEEi, '�1"t 's•BUILDING;PERMITINFO';
Address: PERMITISSUANCE ❑. . . ❑ ❑
LIm that ED CONTRACTOR'S DEC ns of Ch ON
I hereby
n7OODatlam Vicen3oftheunder pmmand a(Cssions (romms< APPWANCESRESIDENTAL JOB DESCRIPTION
IngwVh Senlon700 a atr Dief elon3o(the Buslvesandl'rofeselonsCAde,and my
Rcenu le his fora and effect. PANELS
License CWs Llc.a
w
Date Cantnctor —UP TO 200 AMPS
ARCHITECTS DECLARATION'S 201-IODO AMPS - ^
x OVERIODOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
understand
00
n stand my plans shall be used u public records
CO
lei Z(D Licensed Pmfeesiawl SIGNS ELECTRICAL "
<6 OWNER-BUILDER DECLARATION
SI'LCALCI4CUIT/MLSC
zL,�G IhcrebyafRrtnthatlamexempttromthe Contractorb Llrense Lawlor the
pO following reason.(Section 70115,Business and Professions Code:Any city or
ct,alter, TEMP.METER ORPOLE INST.
countrucrum r.qultesa permit aprovamforsderecasuch permit
g
an DEVICES
lU ksaance,aho requlreethe appBiantfor such pemNno POWER DEVICES
fS file.elgned statement that he Is licensed pursuant to the provisions of the
3" Contractors License Law(Chapter9(commencing with Section 7000)of Divi- VALUATION
Off' a+on3ofthe Busineesand Profemidns Code)orthat he Isexempt therc(romand SWATMING IDOL ELECTRIC .a••�,.
the beets for the alleged exemption. Any violatWn of Section 7011.5 by any OUTLETSSMPCFiF_S FIXTURES
O
applicant for a permitsmare ubjects theapphcant to a civil penalty of not mathan
five 1,as oderofthepre NEW RESIDENTIAL ELECTR SQ.FI'. STORIES TYPE CONSTRUCTION
I,as owner l the property,or he employes with wages r there sole
compensation 74Zhodoth.workandthea Code: h not Intended or offeredI..
O sale(sec apply tea owandf property
Code:The or improve.the.,
the. law
who ddoes ossuch loan ownerf or offprough his o nempoyees,povidedthatand OCC.GROLTP RES.UNITS
EE. wprove ntearekhimeededorwgh hieowale.1r owevervldedtldlegh
Improvementsared withindedoro(feredforsale.theh ev-budderwilI gw TOTAL;
improvem.n[Iswld withlnoneyearofcompletlon,theowner-bu0derwillhave
the burden of proving that he did not build or improve for purpose of sale.). QTY.`;II I� "PLUMBINC.'PERMI7 t, '.I FEE4 FLOOD ZONE APN'
M 1,as owner of the property,am exclusively contracting with licensed pp (IT ISSUANCE
rondoes construct nsctthe project(Sm 7044,Business and Profeslons Code:
The ContnRor's License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wild. or Improves thereon,and who contracts !w such pro)ae s with a
cc u
y�11fIactor(a)licensed pursuant to the Contndofs License Law. N ,t FEE!SUMMARY',', 't
1 am exempt under Sec B& P C for this region BACK FLOW PROTECT.DEVICE
OUTSIDE FEFS
Owner `- '. Date DRAINSFLDOR ROOF,AREA,COND. fSANITARY Y_ N_
RECEIPT a
WORKMANCOMPF SATIONDECLARATION _
❑I hereby affirm FUTIIRE4PER TRAP SCITOOL TA% Y_ N that I have a mrdlcate of consent to self-insure,or RECEIPT M
certificate of Workers Compensation leau rance or a certified ropy thereof(See.
38Oq Lab C.) CAS EA.SYSCFM-]INC.4OUTLETS PARK FEE - Y N
Policy N CAS EA.SYSTEM-OVER 4(EA) RECEIPT a
Com ny - - BUILDING DIVISION FEES
[�C Ifled copy Is herebyfumlahed. I GREASE/INDUSTRL WASTE INTERCEPTOR ANCHECK FEE
enlfied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP' PAID A
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,2001T.. DBIC R�eml t# l$
Rhiasenlon neM not b.completed+f the permit Istalon.hundred dollars
53
(110))or leas.) WATER FSEATERI VENT/ELFOTR ENERGY FEE Y N
s I certify that te the performance ofthe work forwhich this Permit is Issued,
I shall not employ any person In any manner w s to become subject to the WATER SYSTEA1/TREATING
Workers'Compenwlton Lawsof Callfomb. Date PAID
Z Z Applicant NEW RESIDENTIAL 11,11B. SQ.FT. Date Rete. IN
O NOTICE TO APPLICANTg
: aftel ma king this Certificate of Exemption,you
Fshould become subject to the Workers Compensation provisions of the Labor TOTAL:
0 Code,you must fon hwllh comply with such provisions or this permit shall be
W > doem�edrevoked. - BIL ING FEE
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE so
Ihembyof r.thatthere Isomnstroal.lending.g.ncyfortheperfarmF ELECTRIC FEE
MO anceoftheworkforwhlhhIs permit 6 Issued(Sec.3097,CN.C.) TOTAL
(-)
Lenders Name .L/D.ti� - PLUMBING FEE
F Lender.Address QTY. ''.ME r ERMIT' ' FEE !.
LL MECHANICAL FEE
O W Icenitythreetohave mad ythis with allcitlonand dcountethattheafaovedformation
1 Ie correct bugle to complywo ,alndcity hereyauthoomleprese and gate
esoftwe PERMIT 'UAN FEES PAID: J-w�
} cityrelat ng to oenterullont ronswnloryione epbyauthorin repres.npurpso(thls ',s•'Ka
Z city agree
to the,indemnify an
pmpeharrelny ss he Cit purposes. ALTII40R ADDTO MECH.
V (We).Bee to save,indemnify an d keep harMes the City of Cupertino .Date Receipt#
against Isis a,judgments,mets and expenses which may In any way accrue AIRFANUIJNG UNIT(TO 10,000 CFM) - SUBTOTAL:
ag al ty in ronuque a the granting of this "it.
... O�C3O , AIR HANDLING UNIT(OVER 10,000 CFM)' CONSTRUCTION TAX
s reot KpP .ct, - Date IXH UST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appilcant orfutum building occupant store or handle harzrdous HEATING UNIT(TO 100,0D)BTU) Date RCCCj fie
material..defined by the Cupertino Municipal Code,Chapter,9.12, e.the
Health and Safety Cade Senior 2553200? BEATING UNIT(OVER 100,000 BTU) TOTAL:
F1 Yea No
Will the applicant or tum building occupant use equipment or devices VENTILATION PAN(SINGLE RESIU) - ISMANH.DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua Management District? BOILER-COMP(3HPOR 100,0(10 BTU)
IE��M}Y'e. . ❑No
- I haverenelthehuallousmatedl requimm ntsunder Chapter6.95of• BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1 p{, ^
understand that ifthe building dos not currently have a tenant,that it Is my NEWRESIDFNIIALMECFI. SQ.IT. 4�`1 i'{ �41nn1{IRO -
responsibility to notify the occupant of the requirements which must be met
prior to issuance ala Certificate of Ocavpancy. \ E '
Owner or authorized agent Date ISSUED BY,V\O
TOTAL:
OFFICE COPY,