19591 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B°°ding Address: 19591
2 A � .
eros: Phone: AA A
wE plsC- (, CITY OF CUPERTINO-BUILDING DIVISION q
c.nnt.raName: Lie.N.: APPLICATION I PERMIT -TD
D
nn�1'1 I r J BL".NGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL If
ArtMte t/Engineer. Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addo s9
❑ ❑ ❑ M
LICENSED CONTRACTOR'S DECLARATION PFRAITISSUANCE L(�'
Ihereby
t.flrmthatl im9=3ofthe Hosseed underprovidersfmionsCodChapter 9 rom en APPLIANCES ]OB DESCRIPTION
inI,I.MUt000)o(Di effect ofthe Businessancl Pro(mionsCode,and my
license es ins force d c.e PANELS
LlcenseC ss LiC.X6
Date Contrator �� f-ll(— e.-ci
ARCHITECTS DECLARATION WOUTLETS-SMTCHF,%-FFI
MPS
7 I understand my plain shall b,used as publicteoords 0 AMPS SQ.FT.FLOOR AREA $/SQ.FT,
O
Licensed Professional ECTRICAL
�< OWNER-BUILDER DECLARATION IRCUIT/MISC
F' G I hereby affirmthat lam exempt fromthe C mrame.License Law for the
P �Npppp following renson.(Setlon 7m1.5,Business arse Professions Code:Any city or
c.unty which mqulrna permit to wmtmd,alter,Improve,demolish,orrepair IPR OR POLE°NST.
�"�,,1Q anystmu mprlortoltsuwancgalsorequirntheappllcantforsuchperMtto EVICESgUfile a signed statement that M b licensee pursuant to the provisions of the
4k�
Contratori License law(Chapter 9(commencing with Setion 700))of Divi- G Ii�OL ELE Cslon3oftheBusnmandPmmlomCoae)orthathebemm therefmmandVALUATION
gF9 5the bash for the alleged exemption. Any violation of Setion 7031.5 by any
appucant fora permit subjetsthe applicant to a civil perultyefect morethan SMTCHFSE
i Eq
five hundred delta.($50B). NEW RESIDENTIAL ELEC t
I,as owner of theme STORIES TYPE CONSTRUCTION
property,or my employees with wages as their sole
< compensation,will clothe work and the structure bnoe intended or offered for
$ O sale(Sec.7014 Businessand Professions Code:The Contractor's License Taw
P,I�$ don notapply to..owner of property who Wilds or Improves thertor,and OCC.GROIIP RES UNRS
E whodo mchworkhm tforthmughhisownemplaym,pmvidedthatwch
Improvements arc not intended orottered for sale.If,however,thebuilding ce OTAL:
improvement is sold within one year ofcompition,the owner-buuderwlll have
th*rden of proving that hedid na Wnd orimpnve forpurposeofsale.). QTy, PLUMBING PERMIT FEE F1pODZoN ApN
U I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
cotro
ntmors to retrut the project(Sec.7044,Business and Professions Code:
The Contractor's License Taw don not apply to an owner of property who ALTER-DRAIN k VEM-WATER(ErM
Wilds or Imroves pthereon,and who contracts for such ptojtts with a
dor(s)ucensed pursuant to the Comratm's License Law. gA�(p(OIy pROTECr.DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y—•" N_Np
I hereby affirm that I have a
WORKMAN COMPENSATION DECLARATION RECEIPT FIXTURES PER TRAP SCI{(3pL TAX Y— N
I —
certificate of consent to self-insure,ora RECEIPT X
Tab nb CJ.)te-f ,rkers C.mperuatlonlnsurance ora certified ropy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS
3800, PARK FEE Y— N_
Policy If �ja1�/,r--4 RECEI'TX
Cum any CAS EA.SYSTEM-0VER4(FA) BUILDING DIVISION FEES
[�CeAlford copy b herebyburnished,the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
lOCenifled copy b flied with the city Inspetion dlvlalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(ThisseSEWER-SANITARY STORM EA 200FT Date Recei t#
tlon need not W complied lithe permit b for ass hundred dollars
($1Icrifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
111nor that o zany person
In an tmonner so as to b comehis esmubbsuN, —
I shall not employ any person In any manner at ss to become subjet to the WATER SYSTEM/TREATING
Workere'Compunsatl.n laws of Cali(ornb. Dace PAID
O Z Applicant NEW RESI DENTIAL PLMB._SQ,Fr. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould became subject to the W.rken'Compensation provisions.(the Labor TOTAL:
W Code,you mut forthwith comply with such provisions or this permit shall be W > deemed revoked. BUILDING FEE
Il c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lending agency forthe perform Torat: ELECTRIC FEE
Z ance of the work for which this permit he issued(Ser.3097,CIv.C.)
(,) O Linda's Na`"e PLUMBING FEE
LL LendersAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certify that l have read this application and state that theabove Information p
boomou.Iagrectocamplywlthalldtyandcountyordlna.ces..dsiamlaws PERMIT ISSUANCE FEES PAID.
} N relating to building consm
tdlon,and hereby authodm mpresentatin
vofthis
F Z city to enter upon the above,mentioned property for inspection purposes. ALTER OR ADD TO MECH.
V — (We)agree to save,inaemrdfy an d keep harmless the City of Cupertino Date Receipt#
againstlla tle,7adgenente,consan expenseswhlchmaylesnywayaceme AIR HANDLING UNIT SUBTOTAL: 1q.00
gaid ity o n a re a mJ Icosting of this pe
(\ AIR HANDLING UNIT(OVER 1Q000CFM) CONSTRUCTION TAX
Signature.(Appllant/Contractor Dom E%HAUSTHOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturebulldingeccupant store or handle hanrdous HEATING UNIT(TO 100,0)0 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Recei t#
Plealth and SaftyC�lon 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yee o
Will theappflant re building occupant use equipment ordevices VENI7LATION FAN(SINGLE RESID) ISSUANCE DATE
whicheMthavrdou ir contacnnantsas defined by the Bay Area Ar ISSUANCE
QualityMamgement at 7 BOILER-COMPOEIPOR100,000BTU) PaIPnY P
Y o
have read theh a materials requirements un der Chapter 6.95 of BOILER-COMP(OVER 10),000 BTU) v T t9��yil
the Cali(ornla health Safety Code,Sections 2550.5,75533 and 25534. I xlJ 1
undeutxndthatifthc building does t currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.W.
rnponsibuuy to notuy the occupant ft requl mens which must be met µs ,O,
prior mcf Cenl to an CitjEi�86{vo no
�a� . `eil. `"/9/90
t w riu ag nt Date
TOTAL: a ISSUED BY:
OFFICE COPY