19724 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
n
Building PmMd Identification - PERMIT NO. Q 7 f°/�((L
ilding Address:- e 1 �J 1 Y T
Z 2 3 rriTca wn. Y'146 a Y�
CITY OF CUPERTIN4DUILDING DIVISION
ntraoms Name: - Lie.No: APPLICATION / PERMIT9 18111t
yo62y/ BIRLDINGELBCTMCALPLUMBINC-MECHAMCAL CATEGORY CONTROL If
tochBeet/Engineer, Lk.No: - BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Add. 200 S � - 9 SOSr rFxnlrlssuANCE ® 1:1 1:1 .LICENSED CONTRACTOR'S DECLARATION 11
I hereby af@mthat 1 am 11censet under provWonso(Chapter 9(rommene APPLIANCESRES[DEN1AL JOB DESCRIPTION -
ingwlthSedlon7fX1)of DtAslon3ofthe Busimmand ProfasioneCode,and my
license is In fuB(orae and died. - PANELS -
LicenseCh® -29LICN 2n a
Date Contractor
ARCHI=SDECLARA ION / 201-1000 AMPS
ac Z I understand my plans shag be used v public remNs. OVER 1000 AMPS SQ.FC.FLOOR f/SQ.IT.
�y O
(1 Licensed Professional SIGNS ELECTRICAL �I
6 OWNER-BUILDER DECLARATION
ozexemhe SPECIALCI2CIT/MISC
owing meacen5rethem31.5,B(romthe Contactors Eked:Law cityfor or
qqqq countingreason.(&Mon70HS,Business and Professions Code:Mycity it
OZ anystmcoentywhich mpdorbe.aper mealsomquiocommock, athempmvgdennuchper tto POWEREVICES POLE INST.
anyA signed
he is licensed
sed pursuant
to the fo visfem ofNt a POWER DEVICES
5 file a signed statement that he h licensed pursuant la the provisions of the
Contractor's License lAw(Chapter 9(commencing with Section 7000)of Divi- SWNMING]POOL ELECTRIC VALUp2ION
<
�Og
Alan 3oclhe Business and Pmfessioro Code)cellist m
at he ..repitherefroand Q °Y the bush for the alkged exemption. Any violation of Section 70315 by any OUTLETESWITCHESFIXTURES I �O
Applicant for a permit subjeasthe applicant to a civil penalty of net more than
five hundred
owner
rshe pru NEW RESIDENTIAL ELDCTR SQFT. STORIES TYPECONSIRUCTION
I,as owner of of properly,or my employees with wage r their sok
compensation,Buldolhe wwk+ed the sC dum h not intended or offend for
sale(Sec 706E Business and Professions Code:The Contractoh License Law
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.(NIPS
who doessuch work himself orthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.IL however,the building or TOTAL:
improvements sold within one yearofcompletlon,the owner-bu0derwill have
t rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the Property,am exclusively contracting with licensed PERMIT ISSUANCE
rontadms to mnc/roct the project(Sec 7014,Business and Professions Code:
Phe Contradoes License Lew don next apply to an owner a property who ALTER-DRAIN VENT-WATER(EA)
Wild.or Improve thereon,and who contracts fee such ptoJem with a
cgRt(admW unnsed pursuant to the Conmadoes License Law. BAC(FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason - 'ES
DRAINS FLOORROOA,AREA,WND. SANITARY Y N
• Owner Dare RFGEIT M
WORKMAN COMPENSATION DECLARATIONFIXTURES.PER Tis SCi00L TAX Y_ N
I hereby affirm that I have a certlflate of consent to self-Neurc,or RECEIPT a'
Iflate cfWorkers•Comp..tion lesuraeceon certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N
380,Lab C.)
RBCIIPTN
Polley it
CGAS EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
ffnom any
ified copy is hereby furnished. GREASWINDUMI,WASTE INTERCEPTOR PLANCHECKFEE
E]Certulsd copy is filed with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP PAID '
COMPENSATION INSURANCE SLWFR-SANITARY-STORM EA N%IFT Date Receipt#
(This section need cad be completed If the permit hfor one hundred dollars
($100)or In..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the perfomance of the work forwhlch this permit is Wand,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workera CompensationlAws of California.Date PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei [#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should became subject to the Workers'Compensal Ion provisions of the Labor TOTAL:
Tq Code,you mast forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W � coNsrgucnoN LENDING AGENCY - SEISMIC FEE'
CL D I hereby affirmthat there is a commection lending agency for the perform ELECTRIC FEE
M Z no,.(the work which this permit h bereci(Sec.3097,CIv.C.) TOTAL:
L) O I..dera Name - PLUMBING FEE
LL H Lenier'.Addres QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W 1certlfythatl have read this application and statethatthe above Information
O
1 bcormd.Jaime to comply with all city and county ordinances and state laws PE(MiTISSUANCE FEES PAID:
relatingtobullding construction,and hereby authoriP.reprcsentativesofthls
W
L. Z city to enter upon the above�rmntimxdl property fee inspection purpose.. ALTERORADDTOMECH. Date Recelt#
Me)agree to save,-Indemnity an d keep harmless the City of Cupertino
(..1 against liabNtle,judgments,meas and expenses which may In any way ecnun AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit CONSTRUCTION TAX
9 Od"A�` �_21— OO AIRFIANDLING UMT(OVERIO,000CAM)
Slgnatu oApplillcant/rCo'nt_racto-YL Datee EXHAUST HOOD(V/DOLT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the eppuant orfuture building Pa.,store or hand Is har rdous HEATING UNIT CIO 100,000 RTI. Date Recel t#
materhlaedeflned by the Cupertino Municipal Code,Chapter 9.1 2,and the - �r
Health and Salary Code Section Saection 25532(a)? HEATING UNIT(OVER 100,011 BTIR TOTAL: �D
•Jka cat Ye q6O No
_ .
illtheappicat. tam building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) AVISSUAeTE
which emit haezrdous au contaMnares as defined by the Bay Area Air Q�'+'�'4llILD
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) ��
4bawneedtheha>�smateriabmquirem etsunderChapter6.95of BOILER-COMP BTU) �� 21 199[]0/�
the California Health A Safety Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.IT. /s
responsibility to notify the occupant of the requirements which=at be met - City ru—erfi�
P'�jtasuan'�y aCCertificate of Occepanry. - v 'rRl
,6:gA i 2 –2 9a
Ow r or authorlud agent Date ISSUGDBY:
TOTAL:
OFFICE COPY