19704 (2) L
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification - PERMIT NO.
Bundingnddresa: O A
:02.3 2-J6� RCLE L6T 1 n I `� LF
nee one;
Jo$sJ41 T6R1<450C- 295 -z�]8 CITY OF CUPERTINO-BUILDINGDIVISION a �3/q0
Con cne.N.me: a=.N° APPLICATION / PERMIT
(Afffr- W. SK G SOZ SS BUILDINC-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CO LN
ArcMt /Fsginecr. ('+ Lie No:
p ELLO C— - BNC PERMIT4NF0
.5 UAQ �p //s� QTY ELECTRICPERMIT 'q.Ul
Allmea. y y !-a LA A6 PERMITISSUANCE _LICENSEDCONTRACFOR'SDECLARATIONWF
I herebyaffenothatfamlicensed under provWonso(Chapter9(mmmen APPLIANCESRESmENML J N.ingwlthSedton7000)ofDlvlalon3oftheBusimmandProfesionsCodeandmyIlanseislnfu force and effect. � 1 P •� -
Date-eCWs LieN ` PR / TAI ��a�L(JI�'. / .Q/�1/.{J/ (V(J.J
Date-- T_o/-'p1-Contrad aa/a/r�A-`. - 4-•
I ARCH1 CPSD CLARAT—
µQ�Nz IundemtandmyplansshaBbe aspublicrerords. - ER 1000 AMPSI j�- SQ.FT,FLOOR AREA $/SQ.FT.
as
E (7 Liureed Professional SIGNSELECTRICAL•
6❑kGui ', OWNP.R-BUILDER DECLARATION
7a,y 7 Iherebyaffi.that lam exempt fromlhe Contradob Lt...Law for the —
pp"'o following reason.(Section 7031.5,Business and Professions Code:Any city or
OZ'S TIME. POLE INSf.
K� counlywhkh riortoespermitsocowtmuiralter,estheaprovgdemdbh permit
oft any atruaure tatemeltehat ecgabensed pursuant t the provisions
the OWER DEVICES
file a signed statement that k b licensed pursuant to the provblow of the
3: f�. Contractor's License Low(Chapter 9(commencing with Section 7000)of DWI- SWIMMING POOL ELECTRIC
slon3of the Business and Profeslmu Code)orthat he is exempt thumfromand VALUATION
a.•77 the basis(or the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHMFIXTURES q�
O appllcantfora NrMtsubjedstheapplicanttoadviINnaltyofnmmmthan ���r (J U�,
P. five hundred dollars($500). - NEW RESIDENTIAL ELECTR Ff. //
I,as owner of the property,or my employees with wages as their sole �' •(/ SIDEES TYPE CONSTRUCTION
compensatlon,wllldo the work and lhestrumare is not Intended or offered for "
in(Sec 7066,Business and Profesums,Code:The Contratlots License Law
$ docs not apply to an owner of property who builds or improves thereoq,and / OCG GROUP RFS.UNITS'
who doeasuchworklumselforthrough hlsown employees,provided that such ali -
Improvemcnb are not intended oroffered for sale.If,however,the building in TOTAL:
Improvement is sold within oneyearofcompIntien,the owner-bullderwlll have
tl)V: en of proving that he did not buil or Improve for purpose of sale.). QTY. 'PLUMBING PERMIT FEE FLOODZANE APN
I,_j Las owner of,the property,am exclusively contracting with licensed PERMIT ISSUANCE ��r1
contractors to coretmet the project(Sec 7014,Business and Professions Code: y
The Contractors License Law doe.not apply to an owner of property who ALTER-DRAIN k VEM-WATER(EA) -
Wilds or Improve,thereon,and who contra for such platers,with a FEE SUMMARY
off,
licensed pursuant to the Contractor's License Law. BAIXPLOWPROT��T.DEVICE-
LI I am exempt under Sec. B k P C for this reason
DRAINS FT.DDIC ROOF,AREA,CONT. SANITARY Y_ N_
Owner Date - RECEIPT N
s�-H WORKMAN COMPENSATION DECLARATION LIVRES I'FA TRAIT SCHOOLTAX Y N
yJI hereby affirm that 1 have a certificate of consent to self-Insure,ora RFCEB'f N
_. m Rests of Workers'Compenaailon Guurance ora artifled copy thereof(sec, CAS FA.SYSTEh11 INC.d OUTLETS PARK FEE Y N—
I
Lab G) _ RECENT-
. Policy- - GAS EA.SYSTEM-OVER4(EM
Com ert nhlM n 1 BUILDING IVISIONFFES
�Certlfied copy 1,hereby furnished. GREASE/INDUSIR6 WASTE INTERCEPTOR PLANCHECK F'G• /f,Q-�
{7CertlBed copy b filed with the city Inspection divlalon.
CERTIFICATE OF EXEMPTION FROM WORKERSGREASETRAP PAID -
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200FT. :Date RCCCt t#
(this sedlon need not be completed if the permit la forone hundred dollars
($100)or I..J• - WATER HEATE6W/VENT/ELrCTR ENERGY FEE Y N
I certify that in the pedormana of the work forwhlch thli pemdt is issued,
I shall not employ any person In any manner so as to become subject to the WAggR�.ggpM/TREATING .
Workers Compensation Laws of California.Date PAID '
O Z ApplicantDate RESIDENTIAL PCMB. SQ,IT. DRIB Remi t#
Z O NOTICETO APPLICANT.ILaker making thisCertlfiam.fEwen ion,you 4
should become subject to the Workers'CompesaUnn provisios,of the Labor - TOTAL:
fA Code,you=at forthwith comply with such provisions,orthb permitshall be BUILDING FEEr7•
W-] deemed revoked.
.a C CONSTRUCTION the.6.cons LENDING nGDveY SEISMIC PEE 'O
Ihercby cork for that the.iaacovtis Issued
lendinga 7, C.) perform ELECTRIC FEE 'ga4••
L) Z' an.of Lerners work for which this permitbblued(Sec 3097,Co.Civ.C.) TOTAL: -
LL O Landce,Name a PLUMBING FEE
LL LanaerN Aaareaa . QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -
OW Icertl/ythat l have mad this applicat(onand antethattheabove Information
(1 Iawwwr.I agree to comply with all cityand county oralnanmsand state lawn PERMITISSUANCE 1 FEES PAID:
} retailing to building construction,and hereby authorize representatives of this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agree to save,Indemnify an If keep harmless the City of Cupertino Date Rmeipt#
against liabilities,)adgnxwa,was and expenses which may in anywayamme AIR HANDLING UNIT(TO 10,000 CITE) SUBTOTAL'
Id City In consequence of the nb9g his permit.'
d AIR HANDLING UNIT 1go3BCFM) CONSTRUCTION TAX
reof Applicant/Contractor - Date EXHAUS'THOOD(W/DUCT) -' CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE _
Will the appHant orfuture building occupant at..or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCceI t#
materizl as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑Yea No
_ ill the a ppllant or future build Ing occupant use equipment or devices VFNIILATIONpAN(SINGLERESID) t ISSUANCE DATE
whichenith..it ..I,contaminants a,defined by the Bay Area Air -
Quality Management D❑isMdP BOILER-COMP OENOR 100,000 BTU)
EYes N No
ave read the hazy sue matedab mqulrements under Chapter 6.95 of BOILE&C'OMP(OVPR 100,000 B'M II I
the California Health h Safety Code,Sections 25505,25533 and 25536.I
understand that l(the building dcea not mrrently haveatenanhthatitlamy NEW RESIDENTIAL MECH. SQ.FT U la UU
responslbilitytonotlfyth..p.estoftherequlrementswhlchmu,tbemet •� 'ui��( ta -
priortoissuanceofaCertificateof Occupancy. -
- w (�IIPFPrf111A '
y-a•, �t
Owner or authorized agent Date - /-� !"EU
TOTAL: Ti
OFFICE COPY