19916 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address: PTN19 916
Z IC" low .
arc: hone:
vera OL CITY OF CUPERTINO-BUILDING DIVISION '
' contr ale ame//�� �1y Lic.No: APPLICATION /PERMIT
"ewe- `I BURRING-ELECTRICAL-PLUMBINC-MECMMCAL CATEGORY CONTROL
."onect/lu,gineer. Lic No:
,QTY ELECTRIC PERMITFEE BUILDING PERMIT INFO
Address:
PERMITISSUANC•E ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
Ilurebyaffirmthat lamBcensedunder provisions o(Chapter9(commenc APPLIANCES-RESIDENTIAL - JOB DESCRRTION
ingwith Section 7000)of DiAAon3ofthe Budnneand PmfeadonsCode,and m
License le In — d effect - PANELS r
Ice.
.to Contractor �.�a-
AR shall be
LARATION ^^'�I' OVE000 ANTIS" f
pZ � ]understand my plata short be used as pubecremrds OVER 1000 AMPS � SQ.Ff.FLOOR AR S/SQ.F7.
P❑ COC
E U Licensed Professional - SIGNS ELECTRICAL '
<«<� OWNER-BUILDER DECLARATION SPECIAL CIRCUI '
I htmbyafRnnthallam exempt from the Contractors License Law for the _
o following reason.(Stttl.a 70315,Businem and Professions Code:M ct or
r � ¢untywM mqulrnaper wmrub MOter,lmpm ,demolbh,orrepalr WALECTR
ORN
v
any stmc mprlortoits ame,alwrequiren NesppB¢ntfww&pemdtto1file a signed statement that lie b licensed pursuant to the provisions of the 1OLicense Law(Chapter 9(commentg with Sction 7000)of Divi-
don3 ofthe Business and Professions Cade)orthat he b exempt therefrom and VALUATION
the bails for the alleged exemption. Any violation of Stolon 70315 by anyppB¢nt lora peWmt subjects theappgcanttoativiI penalty ofnet m.relheaRv,££,,hundred dol6n($5M. 7R LJ I,as owner of the property,or my employees with wages as their soleSQ'FT' STORIES •CONSTRUCTION
compens.Hon,will do the work.and the swcture Isnot Intended or offered for
sale(Sec.7094,Business and Professons Code:The Contractors Llcmue Lawdoes not apply to an owner of property who build.or improves thereon,andOCC.GROLW RES,UMTS,
whodoeasuchworkhimxlforthrough hlsownemployees,provided tbatsuch
improvemenumnotmtendedorofferedfwsale.ILhowev,,,thebulWingor TOTAL:
improvemeatbmld within meyearofmmplmbmtheowner-budderwill have
lfLilurden of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING.PERMIT FEE EIRODZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7044,Buemess and Profeesbns Code:
The Contndorb License Law don not apply to an owner of property who ALTER-DRAM k VENT-WATER(EA)
builds or Improve,thereon,and who contnde for such p(ojeda with a
agRll+d.r(s)Licensed puniant to the Contndora License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sen ,B 4 P C for this reason
nUTSIDF FEES
DRAINS FLOOR AREA,ROOF,A SANITARY. Y— N
.� Owner Date r ,COND. - _ RECEI T a
WORKMAN COMPENSATION DECLARATION FIX'NRES PER TRAP SClfOOLTAX Y— N_
QI hereby affirm that 1 have• Indoorte of consent to o y-tnan,w e. RECEIPT f
certRl¢teolWorken'Cwnpensetlm insuranceora¢Willed copy thereof(Sec. GAS FA.SYSTEM-1 MC40UTLE75
3SOO,Lab C. ^ems 607 a PARRFEE Y N
Corny rev . C—CJ ` GAS EA.BYSFEM-OVER 4(EA) -RECEIPT N -
.ahe /(�77 BUILDING DIVISION FEES
�Ceni ied c. y b hereby furnished.acity CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
- �CertNed copy b Ned with the dry Inspection division. "
CERTIFICATE OF MEM"ION MOM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700Ff Date Remi tN
(Thls.edion need red m
bemplded If the permit b(Drone hundred dollars
($]00)orlba MWATER HEATER W/VENT/ELECTR ENERGYFEE Y 'N
Icerti(yytthat the performance.(the work forwNch lM1le pertnit lebmed, '
I shall not employ any person N any manner an u to become object to the
Workers'Compensation laws.(California.Date WATER SYSTEM/TREATING PAID
.OZ Applicant
Z O NOTICE TO APPLICANT.If,ager making this Centiflcam of Exemption,you NEW RESIDENTIAL PCMB. SQt7, Date 'Revel tN
should become subject to the Worker'Compensation provbioes of the Labor - TOTAL:
N Code,you muatfarthwuh comply withsuch provins
slaorthb permit shell be LNG
W >. deemed revoked. - '
d c CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby sat thattherebaconstructionlendingagencyforthepedorm-
M zO .n¢.fthewwkforwMchthbFermltblw d(See3097,CIv.C3 TorA1: ELECTRIC FEE
LL <"Idere Name PLUMBING FEE
F Lender's Addreea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certitythatl have read this applicatbnand statethattheaboveinformation -
bmrred.Iagr¢to complywlth all city and countyordlnancesand urate laws PERMIT ISSUANCE FEES PAID:
Nrelating to building construction,and hereby authorize representatives.(this -
F— U) city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.e) Date ReCe1 the
Z (Wagree to save,Indeharmlessly an d keep harmless the City of Cupertino P
against liabilities,Pilgerents,costa and expenses which may In any way amme AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL,
aga Wt said City In consequ of t antin Qf this permit •
AIR HANDLING UNIT(OVER 10,0DO CFM) CONSTRUCTION TAX
f Appbcent Co dor r Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR US MATERIALS DISCLOSURE
Wllltheapplinnt or lure building occupant store or handle hazerdous HEATING UNIT OO 100,ODO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date ReceiriW
Hcalthand Safety Codc25537(a)7 • HEATING UNIT(OVER 100,000 BTU)- TOTAL: _
❑ Yes
No
WWthe dppliont or tore building occupant use equipment or devim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
,• which emR hazardous ab runts name act defined by the Bay Area Air
- QualityM nagiurmm Dbt BOILER-COMP.OID'OR10QMUTU) ' p�(,D
- 4 Yee No el
haveread the fealth ar our Coale,le requirements 5533under
and 255 .1 of BOILEi-COMP(OVER 100,000 BTU)' /
the Califomla Elealih k Safety Code,Sections]550.5,75537 and 25534.!
understand that if the building don not currently have a tenant that it Is my NEW RESIDENTIAL ME(H. SQFF.
rest nlb0itytondlly th mipant of the requirements which mod be met JJ
r canon.Ma 1 ant. - C1 h -
Wer or authorised ant t )ftte ISSUED BY
TOTAL:
OFFICE COPY