19582 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PWcct IdentificationPERhfITNO.
Ila hiding Addmss: Af A/ - 19582
wnere soon Phone: APPL1CATT573U9RTTTAL=
5 o//D CITY OF CUPERTINO-BUILDING DIVISION v
Canmen .Name: Lie.No: APPLICATION /PERMIT i Z 1 6
BUILDINGELECTRICALPLUMBING-MFLHAMCAL CATEGORY CONTROL a
Archltett/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I Mrebyafn7O thal amfDiviscen3oftheunder uMne andP fmioner9(rommmc- APPLIANCES-RESIDENTIAL JOB DESCRB'170N
Ingwlth& fol 7000)of d dieon3ofthe8uslnessand ProtemlonsCode,and my F
L=ose is in tulljo�- d eftee. O// O pANDs
License/CI( ss C LIc.N Y
Date Q_CHITECr �� UP IV 20 AMES
201-1WOAMPS
ARCHITECT'S DECLARATION
�Z I understand my platy.hao be used as public movies. OVER 111p1 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
Licensed Prolessloml SIGNS ELECTRICAL
<= OWNER-BUILDER DECLARATION
< Iherebyaffirm that I am exempt from the Contractors License Law for the SP[C ALCE CU T/MSC
79--s following reason.(Section 7W1.5,Business and Prefevlons Code:Any city or
0 t µSI countywhlchrequlrmaperMttoconimM ltegbnpmve,demolIsh,orrepair TEMP MEfYR ORPOLE]NST.
P5 .'ti anystme mpdortoibi ance,aL+ m-quirestheappHuntforwchpermitto -
q U file a signed statement that he Is licensed pursuant to the provislom of the POWER DEVICES
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
F Oe slon3ofthe Buslnessand Professions Code)orthat he Isexempttherefeme. VALUATION
g <9the tsmu for the allegod exemption. Any violation of Section 7f131S by any OUTLETSSWITCHESFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not room than
live hundred1,asownerof t(5500). NEW RESIDENTIAL ELECTR SQ.FT. STOIUES TYPECONSTRUCTION
�,< compensation,
wit] oche wor"edthe pmperty,or my employee withwagesr fferedfo
eomperaat0K wllileass nd Pm.km;uudu Thre Is C.. iet.e oroffered
5 ❑ site(Sec.apply
to alnem ami f grope ty Cade:The C improves Licesue law
whoddoesnol apply torn owner ofprough hisonempbuilds orees,preted that such
OCC.GROUT' RFS,UNITS
EE lmpd ea ntsa orkMmtendlf through hisown er,thedthatwch
Improvement issold lntendedoroofcre ormle.t ho ever,theerwilI have TOTAL: �)
ImprovemanHasold wilhinoneyearo(completion,theowner-buLderwill have
t� rden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FICODZONE APN
6L as owner of the property,am exclusively onrometteg with licensed PERMIT ISSUANCE
motmctors to construct the project(Sec 704A Business and Professions Code:
The Contraaoes License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER MA)Wilds or Improver thereon,and who contracts for such p(ojects with a FEE SUMMARY
ogBt_[=dor(.)licensed pursuant to the Contraeoe.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT p
WORK MAN COMPENSATION DECLARATION FIX.fURFS PER 1OOLTAX Y_ N
❑I hereby affirm that 1 have a l rt rare of ao Alf to pythe rc,or RECEPT 0
cert((Imte o(Warkeri Compenmtlonlreurance ora=rti(Icd copythereo((Sec. GAS - WC OUIL' ARK PEE Y N
3800,lab CJ ,AA
Comryanv ( O GAS .�1'1'Q.4? ER tEA RI:NGDIp
_fa_ BUILDING DI VISION FEES
Certlfled mpyls herebyfumis d. Cl
FP LANCHECK FEE
Carolled copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPFION FROM WORKERS' E AID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.RAFT. Date Receipt#
(TWlssectlon need not be completed tithe permit Is(prone hundred dollars
($I00)ort..) WATER HEATER W/VEM/ELEC'1'R ENERGY FEE Y N
I certify that in the performanceaf the work forwIssued,ch this permit is Issued,
1 shall not employ any person In any manner w as to become subjen to the WATER SYSTEM./TREATING
Workers Compensallon Laws of California.Date PAID
O Z NOTICE
OTICApplicaE NEW RESIDENTIAL PLMB. SQ.FL Date Recef t#
ZO NOTICEco MPLICAM:ILaferers'Copmaking er Certiflproviomoftcate of teLyou
should become subject to the Warken'Comperamion provIsloe of the Labor TOTAL:
CC U) Code,you must foil hwith comply with such row6iora or this permit shall be
LU j dean revoked. p y p BUILDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d z Ihereby affrmthat there bamrutruction lendingagency forlhe perform TOTAL: ELECTRIC FEE
7 Z snmoflhe work fprwhteh this permit Is Issued(See.30W,Civ.C.)
O O lender's Name PLUMBING FEE
LL Lendee.Addres, QTY. MECHANICAL PERMIT FEE
O w Is
IaaLytbatlhavemadthIsappL=tmnandmatethat'heaboveinfomadw MECHANICAL FEE
IL corned.l agree to comply with all city and county ordinance and nate law. PERMIT ISSUANCE FEES PAID:
W relating tobullding communion,and hereby authorise representatives of this
city to enter upon the above,mentloned property for inspection purposes. ALTFRORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmines the City of Cupertino Date Receipt#
V against llabillties,judgments,costs and expenses which may In anywayaecrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against mid City In consequence of the granting of this permit. CONSTRUCTION TAX
- AIR HANDWNG UNIT(OVER 10,000CFM)
Signature of Applicant/Contmetor Date EXHAUST 110013(WI DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applies cat or forme building occupant store or ha cad lc haaardous HEATING UNIT(TO 100,ODO BTU) Date Recei t#
material as den ned by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Coit alt tloo 25532(a)4 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yrs of®(�uNo
Will the applicant rebuilding occupant useequlpment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit bav rdous air rants minante as deli ned by the Bay Area Air ��$®'+
Quality Management D' ct1 BOTLER-COMP PU) AIR'OR IWM BT
4Ye Na
havemadlheh material mquimm ntsunder Chapter6.95of BOMER-COMP(OVER I00'"BTU)& ioe JAN
r� n 199('
the California I ImlthSafety Code,Sect25505,25533.ed 25534.1 r le V
undenlandthatllthebuildingdoe.namrrenllyhavca tenant,that It Is my NEW RESIDENTIAL MECH. SQ.Fr a
responsibility to notify the occupant of the requirement.which at be met
prior to Issuance of a Certificate of Ocmpanry. City of Cona►fl
Owner or authorlud agent Date
TOTAL: ISSUED BY:�
OFFICE COPY