19500 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prem Identification , PERMITNO.
Md..: 19500
ners Va ZSS h2X xA.r•f]Z.`A A
wlY bR CITY OF CUPERTINLLBWEVtAG DIVISION
CoW,47rs Name: Lk.No:
Y,v c �i394 : APPLICATION /PERMIT CATEGORY coNTRol.a
Architect/Engineer: ! Llc No: BUfLDING-ELECTRICA4PI,UMBINC-M[CFNMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERhBTISSUANCEak•UO ❑ 2N, 1:1 - [1LICENSED CONTRACTOR'S DECLARATION
I hereby
oction70 that) tvt90 sed 3ofthe er Businevlsdvsre Cssions9de,and e- APPL[ANCFSRESIDENTNL ]OB DESCRB'770N
'ngwdh Sc fuLimrsoCla.11 700p)of Dl effect ofthe Budncssand ProfesalonsCode,and my
license is in full! and effect PANELS
Date Con,nctor a v aX'2'G V elvf
�✓l
ARCHITECTS DECLARATION 201-IODO AMPS
7 I understand my plans shall be used as public records. OVER 1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
O
d Licensed Profenslovl SIGNS ELECTRICAL
ry V go
<L goSIGNS
DECLARATION
I-n Fit SPECIAL CIlZCUIT/MLSC
7p Ihercby affirm that lam exempt from the Cont raters License law for the
following ream.. ecton
folli (Si9031.5,Business and Professions iCode:Any city or TEMP.METER OR POLE INST.
� countywhich rcqulresa permit toconstruct,alteq improve,demolish,or repair
any structu m prior to its issuance,aim requires the applicant for such permit to POWER DEVICES
aV file a signed statement that M b licensed pursuant to the providers of the
0o' Contractor'.License Law(Chapter 9(commencing with Section 7000)of DIW- SWpdtgNG POOL ELECTRIC
30 cion I mine Buainessand Profs lav Code)cribs,he is exem hensfromand VALUATION
y.'S the Weis for the alleged exemption. Any violation of Section 7G31.5 by any OUTLETS—SWITCHES-FIXTURES
6i applicant fora permit subpRetheapplican,to a civil penalty mint marathon
w five hundred dollars(550M. NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPECONS'1RUCTION
G 7 6 ❑I,as owner of the property,or my employees with wages as their sole
compensation idoheworkandhestmq coin Mended or offered for
(Se
O vie c.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RES UNITS
CC.. who does such work himself ortheaugh his own employees,provided that such
Improvements are not Intended oroffered for sale.If,howevegthebuildinger TOTAL:
improvement b sold within ane yearofcompltlon,the owner-bullderwill have
t"rden of proving that he did rat build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I_I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contnctmrs to mnslrot the project(See.7044,Bush.and Pvfessbv Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER OW
or improves thereon,and who contracts for such pi jeta with • FEE SUMMARY
m,LSjactor(.)licensed pursuant to the Contractor'.License Law. BACK FLOW PROT[CT.DEVICE
LJ I am exempt under Sec. B &P C for this reason
DRAINOOR,ROOF,AREA,COND. SANITARY Y N_
Owner Date S FLRECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP 5CIi00L TA% Y N
❑1 hereby affirm that I have a certificate of consent to self-Insure,ora RECE0r1'X
certificate of Workers Compensation Insurance ma certified copy thereof(Sec GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE YN
3800,Lab C.) S _
RECEIPT_ N
Policy X GAEA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FRES
Ce
copy is,hereby furnished. GRFASE/INDUSTRL WASTE INIIRCEPTOR PLANC14ECKFEE
Certified copy b filed with the city inspection division.
CERTIFICATE OF E%EM ITION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY STORM EA"FT. Date RCCCI t#
TThbmtion need not becompleted tithe permit b forov hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certifythat Nthe r(oican 1. ewml grwhlch the /rad
1 shall not employ person n man m u, col t the WATER SYSTEr7/'Di[ATING
Workers Comp len Lawaof If .Date u PAID
0 Applicant eek r NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
O NOTICET(�'APPLICANT:If,after making thisCertificate of Fxem i you
should become,subject to he Workers Compensation provbions of the Labor TOTAL:
cc w Cade,you comply with such provbbv orthb permit shall be BUILDINGFEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. O I hereby affUmthat there is a construction lending agency for the perform- ELECTRIC FEE
7 Z ance of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL:
00
Lender'.Name PLUMBING FEE
LL l 1<nder.Addre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedlfythatl WvercxdthbappBcatbnandstatethattheaboveinformation
1 Lscomet.lagree to comply with aRttyand counryordlvnces and nate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and herebyauthorthm representativesofthis
F W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.
Z (We)agree to save .deme fy an it keep harmlem the City of Cupertino Date Receipt#
V .,.last) 'ides,ju nb ,sand ex ssehiehR manywayaccroe AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago city ceof thi. scat
r _ AIA HANDUNC IINTT(OVER IB,BBBCF.M) CONSTRUCTION TAX
Ignamreof Appldc..t/Contractor to IXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUR
Will theappAant re few.building occupantstemcu Fondle havamlou. HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _
Health and Safety CodYealre_Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
�
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSItjeA7AIG.EsDATE.
which rout
anaement air contaminants manta asdefined by the Bay Area Air
Quality Management Dbtcit7 BOILER-COMP PER'OR 100,000 BTU)
4 Yes 1—I No
Tuve read the haze sus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) V �JS0
the California Health&Safety Code,Sections 25505,25533 and 25534. I
undersea nd that if the building does not currently have.tenant,that it b my NEW RESI DENTIAL MECH. SQ.FT.
responsibility,to notify the omnpa nt of the rcgWrements which must be me, City of furrertino
prior to issuance of a Certiflate of Occupancy,
Owner or authorized agent Date TOTAL: ISSUEDBY:y� 0A vCL,
OFFICE COPY