21938 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add nesi
A 3TC NI S
2193&
ser arra: /uV one: A
CITY OF CUPERTINO-BUILDING DIVISION
Contra 'a Name: Lk.No: APPLICATION I PERMIT [
LAI�Iafs
4AAMBUILDINGELECTRICAI PLUMBINGMECHANICAL CATEGORY CONTROL a
' rchitect/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
Address: PERMITISSUANCE El ❑ ❑
LICENSED CONTRACFOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(corrmme. APPLIANCESRESIDENTIAL JOB DESC ION
I i ..Sect1on7000) vlelon3a(the Buelne--Cade,and my to ,(��
Bcenss{s in,ryJ�,���—( dd(ect PANELS ^ '
License Cls I,IcR (`���—
DateContractorUP TO 2DO AMPS
ARCHITECTS DECLARATION' 201-1000AMPS
q Z I understand my plaw shall be used as public records. OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
❑O
L•U(a Licensed Professional SIGNS ELECTRICAL "
<< m OWNER-BUILDER DECLARATION
In� SPECIAL CIRCUIT/MLSC
Oi., owing ason.(hatIsm 31.5,Business from,
the sad Professions
License Code:Any
for t he -
02..�oo countywreason.iresaprmitto Business and Pimprions Code:Any cityir
TEMP.METER OR]'OLE INST.
county which requlreaapermi[tororisWR,alter improve,demolish,orrepalr
qanystmc mpri Wiro bmamc alsorequireslheappncantforsuchpermitro ['OWER DEVICES " � '®
E5 file a signed statement that he Is licensed pursuant to the provisions of the
Q6 3 Contnnorb License Law(Chapter 9(commencing with Seaton 7000)of Divi. SWIMMING POOL ELECTRIC 11 n UA ON
H�OJ sion3ofthe Butneasand Profemio Code)orthathebexempttherefmmand qVA
6.•�77 the basis for the alleged eaemptbn. Any violation of Section 70115 by any OUTLETSBW[TCHESFI%TUR _
❑ applicant fora permit subjectathe applicant to a civil penalty dnot nnre than
five hundred dollars($500), 0I' TYPE CONSTRUCTION
'❑I,as owner of the pmperty,or my employees with wages as their sole
NEW RESIDENTIAL ELECTR
compensation,will do the work,and the structure Is not intended or offered for
0 In(Sec.70"Business and Professions Code:The Contracim's Licerae Law
[�$$• does not apply to an owner of property who builds or Improves thereon.and OCC.GROUP RES.UNITS
C: who dueasuchw.rk himself orthrough hie own employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcomple lon,the owner-builderwlll have
ttden of proving that he did not bund or improve for purpose of sale.). QW. PLUMBING PERMIT FEE FLOOD ZONE APN,
6I,as owner tr the properly,am exclusively contracting with]sensed pRRMLp ISSUANCE
The Ce trstomruwnsect Law
oesSec.appy Business andProfessionsof
Code:
The Contractors License Lew aces not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds t r improves thereon,and who rontrecta for each p(ojecb with a FEE SUMMARY
coL_jI am
or eexemptt underpursuant rothe ContrcRor'e License Law. BACK FLOW PROTECT.
I am exempt under Sec. B&P C for this mason
OUTSIDE FFFS
DRAINS FLOOR ROOF,ARRA,COND, SANITARY Y N
Omer Date RECET'r p
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP .V SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-insure,or a - RECEIPT M
cedifimteofWorkere Compematlon Imumnceoramnifiedcopythereof(Sec.
3800,Lab CJ GAS EA ST SYSIT111JC 40IIILEI5 PARK FEE Y N
Pori N GAS EA.SYSTEM-OVER 4(EA) 'fM
Com a y BUILDING DIVISION FEES
�.ertNed copy b hereby ththcity
e city inspection divdivision.e
hed
Certified copy V filed with th - GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE e
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONANTE SEWER-SANITARY-STORM EA.2WFT. Date Recei t#
- (Thlaeectlon need not becomplted if thehepperer mit is(orone hundred dollar
($100)or less') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifythat in the performance ofthework forwhich this permit is issued,
I shall not employ any person in any manner so as to become subject to the WAT'FR SYSTEM/TREAI'INC .(/V PAID
Workers'Compensation laws of California.Date
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.FT.' Date Rece1 t#
O NOTICE TO becomesubjeAM:IL orkerftar akompee Cettifkrovis Exemption,you
H Code,you=at
forth ithto co Worsen'Comp roviinprovbim permits of s Lab be TOTAL:
f/I Cade,youmuat(othwilh comply with such provisions or this permit shall be
LUQ deemed revokes. S BUILDING FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hambyaffirmthat there is amostruttlon lendingagency forthe perfarm TOTAL, ELECTRIC FEE
Z
ance of the work for which this permit is Issued(Sec.3097,Clv.C.) a•CG
OO Leaders NamePLUMBING FEE
IL 1= Lender'BAddresB QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I nertilythatl have read this applicationand tatethatlhegmw information
f1 iscorrect.l ugresto comply with all city and county ordinances and tate laws PERMIT ISSUANCE - FEES PAID:
} to relating to building curmtmtion,and hereby authorize representatives ofthis
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Recei t#
V — (We)agomto save,Indemnify an d keep harmless the City of Cupertino P
.11.44st liabilities,ydgments, teandexpenseswhichmayme.ywayamue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL' Q
I tealdC Inmcn.4 of the granting at this permit AIR HANDLING UNIT(OVER lO,WOCFM) CONSTRUCTION TAX
tCONSTRUCTION TAX PAID:
Signature pplicaot/Con
Factor 'Date EKHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCYOSURE
Will the applicant orfuturc building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
health and Safety Code Setlon25532(a)? HEATING UNIT(OVER 100,000 BTU)
❑ Yes No TOTAL: 3`a�a
e at)�
Will the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISStPA(fAATE
which emit hamnicus air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP THP OR 100,000 BM
❑ materials
F1No
]have read the hazardous aterials requirements under Chapter(,95 of BOILER-COMP(OVER 100,000 BTU) MAR 18 19,91 -
the Califomla Ilealth&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a Imam,that it le my NEWRESIDENTIALMECH. SQ.FT.
responsibility to not ify the occupant of the requirements which at be met (�r �asat4�s�..4.,
prior to Issuance of a Certificate of Occupancy. X44,/ 6d cwtrsT
Owner or authorized agent Date ISSUED BY: a QkVC..yt,
TOTAL:
OFFICE COPY