19697 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project]Jen Oflatlan - PERMITNO.
Building Address:_
D2o3j 05-EPH CI R.c.Le L OT 19697.-_
neveams: phone:
,OSEPp FARO Assoc. CITY OE CUPERTINO-BUILDING DIVISION
C3tractor's Nacre: Lic. APPLICATION / PERMIT os,
JAKES SISIG SdZq J BUILDING-Q,ECTRICAL-PLUMBING.MDCHANICAL CATEGORY CONTROL X.
Arch ted//En neer{., Lie No: V e
�'a'v L=� G^ I BUILDING PERMIT INFO
s C-a2y A QTY ELECTRIC PERMIT FEE
Addrcse: d PIRbBTISSUANCE �2!
LICENSEDCONTRA OR'SDECLARATION
Ihereby affirm that l am licensed under provision.ofChapler 9(commeno- APPLIANCESRRSDENTIAL - JOB DESCRIPTIO
I ag with Section 7W0)of Division3afthe Buelnewand Profesk...Code,and my C
license 1.in fol me and effect -. PANELS ' ' �I
Llren.Claes ' -Lic.p S _ DI"
Date ContractLIP 102DO AMPSseer
ARCHIIE S ECLARATION 201-1000AMI'S
��qquu s,l 7p I understand my plam shall be used wt public retards. OVER I OBB AMPS /SQ.FT.FLOOR AREA g/SQ.FT.
6i o Licensed Proefineloml SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC -
Iharcbyafflrmthatlam exemptfromth.Contrador' cemelawfmthe PeA
O lo0owing reason.(Scation70315,Bsi
unessand Pron TPMP.MET[RORPOLE]NST. 6fees e:My city or /, G
rr4F• county which requires.pernditeconstruct,alter,imp ve,demoBsh,orrepalr � -
O7 a eystmdureprlortoibimeto e,alw Irca the p can(for such perrNt to POWER DEVICES
5 Ole a signed statement that he V Ilceme puma he provialom of the
o. Cmtradorb LImmel.aw(Chapter9(m a th Seelo 70M)ofDWi-
�OS elan 3 ofthe Buslneasand Prof in Code r he exe hercfromand SWNTMINC POOL ELECT RIC VALUATION
Q the basis for the alleged exemptly Any ion o Se L5 by any OUTLETSSW[TCFIESFIXTUAES / �-�}•� x
H v V
appU..t fora pernJtsubjedsthea IIc acivilml mare than
QOve hundred dollars
u. NEW RESIDENTIAL ELECTR SQAT. .
tttJJJ f as of the •O9 SI'OWES TYPE CONSTRUCTION
�n ❑, P ork,a r employ a It wagm.1 offered
3
compensation,So.owol r
orka hes �? re n ended License
eLaw
$ O ease(Sec.76iq Buslne d lora ¢'7 e Con adore Llrense law -
$ doe.nal apply to an r rope o Hda or Improves lhermn,and OCC.GROUP RM.UNITS
who daa such work orthrou h Is employees,provided that such
improvements are no I en edoroffe reale.If,howeveq the building or TOTAL:
Impme,menttssold hm-myeary Iedon,theavner-bu0derwillhave -
ItgIIurdenofprovin that hedld netball r Improve for purpomo(sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed - ppRMIT ISSUANCE
matractora to comirud the pmjM(Sec.704y Business end Profenlans Code; G
The Contrador'e License Law does not apply to an owner of property who ALM-DRAIN k VEM-WATER
Wilde or Improves,thereon,and who contracts, for such p(ojeds,with a
cq�Dador(s)licensed pursuant to the Contractor'.Llmme Law. FEE SUMMARY
I�I am exempt under See. B h P C for this reason BACK FLAW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,ASIF&COND. SANITARY Y N_
-� WORKMAN COMPENSATIONDECLARATION RECEIPT#
ffi
I hereby arm that I have a certificate of convent to self-?muco,or a S"PER TRAPRECEBT a SCHOOL TAX Y N
este of Worken'Compewtlonlnsurance ma ttrtlfled ropythereo((Sm. GAS EA SY I PARK FEE Y N
3500,Lb CJ Policy#_ '- RECEIPTM
Com GAS-EA.SYSTEM-OVER 4(PA)
a Y_ I BUILDING DI,VISION FES
CetllOed copy erc -(urnlahed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK PEE
Certified mpy s filed with the city Inspection division.
CERTIFICATE OFFXEMPTION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.400FT. Date Remi f#
(Thls.edion need not W completed If the permit la farom hundred dollars
(5100)orlyth WATER HEAATTR W/VENT/ELECTR ENERGY FEE Y, N
]certify that o the person i a any
lm rounweak forwhkbommu,rubra Ito the
I shall not employ any person f any manner n m to become subject to the WATER SYSIT m/TREATING
Workers'Compensation laws of California. Data PAID s
O Z Applicant NEN'RFSIDPNIIAL PIAIB. SQ.FT. Date Recei HI
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemptlon,you
should became subject to the Workers'Compensstlon provlslone of the Labor - TOTAL:
W Code,you nwst(ort hwlthmmptywlthauchpro 6101 .orthls,per tehaltbe
m
deeed revoked. - - U
W C CONSTRUCTIOMLENDINGAGPNCY - SEISMIC PEE / l
CL Iherebya(flren that there s a construction lending agency for the perform 0q ELECTRIC FEE
Z ante ufthe work for which this permit is Issued(Sec.3097,Civ,CJ TOTAL: s, 2
u2 _ Lender's Nacre PLUMBING FEE ^ .(��J
IL /- Lenders Address QTY. MECHANICAL PERMIT FEE, MECHANICAL FEB '.
O,W I really that l havereacithlsappliestlonand erste thattheabove lnformatlon h
lamreact.F agree to comply withal)dtyand county ordleance,and state laws PERMITISSUANCE - f— PEES PAID:
�• N Matingtobullding construction,and lumbyauthadze reposentativeeofthia -
F- Z - city to enter upon the abovcmenlbnM property for inspection purpose. ALTER OR ADDTO MUCH. DBI. ReCel IN
— , (We)ag..to save,Indemnify an d keep harmiess the City of Cupertino - - P
sgainsthabllitim,judgmens,roes and expenses which mayln anywayamme AIR HANDLING UNIT fro 10,000 CFM) SUBTOTAL: I
ag.imt a id City In mmol ance.f he grant gof this permit
AIRHANDLINGUNIT(OVER10,000CIM) - CONSTRUCTION TAX
�� 2- -3 -
slgn vre of Appllant/Contractor Date E(HAusTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies at or future,building occupant store or handle hacardous HEATING UNIT OID 100,000 BTU)
matedalas defined by the Cupertino Municipal Code,Chapter 9.I$and the - Date Recei—IN--�
I lealth and Safety Code Section 35933 W?' HEATING UNIT(OVER 100,000 BTU) TOTAL:
I�
Y. No
"rylllthceppilantoruture Wildlagoccvpart ace equipment or devires VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit m.rden s air mnhmimme s.cie0aed by the Bay Area Air
Quality Management District? r BOILER-COMPOHPOR100,000 BTU) pp/�
I Yes goNo
have read the Health
& Tet Code,materile Sect
2men.25533 ad 25534. 1 of BOILER-COMP(OVER 100,000 RTU)
the Gasiform.Heade h Safety Code, lvmntlyh have
alcnd755M. I n 7 iy Q�
respomandthat lithe actify the occupant
net a nentlyhavea tenancy that ltlamy NEW RESIDENTIAL MECIi. - SQ.Fr ,Q
i responeibllitymndily, the occupant o(the requlremens which mus(be met '
I prior to Issuance of a Certificate of Osco pa acy.
. City of Cunartinn
Owner or authorired agent - Date - '
TOTAL: ISSUED BY
OFFICE COPY