19727 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: vi' ['V ��� k�S- b 19727
N��h � V\
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—7320 CITY OF CUPERTIN46UILDINC DIVISION pA
LIc.No: APPLICATION /PERMIT
YRA_a- h
BUfLDINGELF =CAUPLUMBINGMECIIAMCAL CATMORY CONTROL
Architect/Engineer. U Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PFRnanssUANCE - ❑ ❑ ❑ IV
LICENSED CONTRACTOR'S DECLARATION Locl_
I hereby affirm that l am licensed underprovbi.ns o(CM1apmr9(mmmenc- APPLIANCFS.RESIDENML JOB DESCRIPTION
'ngwith Becii. 'd W.do(t¢e�rne��m dmy
license h in(u orad dfen. //TT// J PANELS �a
Licenx C ' GO Lk.N M
Drte Contractor 3011000 AMPS
ARCHITELARATION OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Ont 7 I understand my phro shag be used u public records.
EdoSIGNS ELECTRICAL
U�j Licensed Professional
OWNER-BUILDER DECLARATION
p, Thereby affirm that lam exempt from the Contractor's License Law for the SPECIALCIiCUT/M
%O-9� following reason. 70315,Business and Professions Code:Any city M
ty or TEg METEROR EINST.
F
county which requlreta permit tocom uct,alter,improve,dersollsh,°rmpair
ggqym anystmMmpdortoitstsauance,ahomqulmatheappllnntforwchpermitto POWER DEVI
C o. file a signed statement that he Is licensed pursuant to the provhloru of the
3 u, son radon'auiceneveLow and(Chaps r9 Codc encinghebe�mo th0000)of coned SWIMMNG L ELEC C VALUATION
p !5 the basis for the alleged exemption. Any violation of Section 70312 by any OUTLE MHES
4S' <� applicant fora permit subjects the applicant to a civil penalty of not more than
n. five hundred dollars(5500).
9..' �1,as owner of the property,or my employees with wages as their sole NEWADFjCTR SQ'FL STORIES TYPE CONSTRUCTION
mmpeneatlon,wlll do the work and thestructure Is not intended or offered for
O ssle(Sec 70K Buairess and Thofessioro Code:The Contractor.Llcerse law
docs not apply to an owner.fproperty who Wilds orlmprovnthemon,and OCC.GROUP RES.UNITS
who does such work himself or through hisown employees,provided that such
Improvements are not intended or offered for sale.If,however,the building or TOTAL:
Improvement insold within one yearofcomplelon,the owner-builderw9I have
thallia den of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
IJ L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.701 Business and Professors Code:
The Contractor's Llrenx law does not apply to an owner of property-who
ALTER-DRAIN&VENT-WATER(EN
o9lids or Improvse thence,and who contracts for such ptojem with a FEE SUMMARY
L_JI or(s)xempt pursuant to the Contractor's License Law. BACIK FLOW PROTECT.DEVICE
t�I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAI NS FLOOR ROOF,AREA,CO D. SANH'ARY Y_ N_
• Owner Date RLCEBTM
E31 hereWORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
by affirm that i have a certificiateuminc .i consent to self4itsureopythemo ora RECEIPT N
a olicy4eofWorkerd Co/m�p�eroation 'u_I Foracertifle copy thereof(Sec. GAS EA,SYSTEM-1 INCA Ens PARK FEE Y_ N_
3900,Lab C.) RECEIPT�l$3� „
P011ry p-�r V!! V r RECEIPT N
Com any_�Z GAS EA.SYSIEMAV X4
(EA) BUILDING DI VISION FEES
Certlled copy Is he by furnished. GREASE/INDUSIR ASMINTERCFPTOR PLANCHECK FEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SA ARY-STORM EA 3DOFT Date Recti t#
(This section need not be completed If the permit Is for one hundred dollars
(EI00).r 1en.> WATERT TTRw/vENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of the work for which this permit Is Issued,
I shall not employ any person In any runner x as to become wbjM to the WA SYSTEM/TREATING
Worken'Compensatonlawsof Califomh.Date PAID
0 Z Applicant RESIDENTIAL PCMB. SQdT. Date Remi t#
'Z O NOTICETOAPPLICANT:ILafter waking this Certificate.!Eweeption,you
h' W should bemnesubjcd to the Worked Compensation provisions of the Labor TOTAL:
� ;
Code,you must forthwith comply with such provisions ortLb permit shall be BUILDING FEE
seemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there h a construction lending agency for the perform TOTAL: ELECTRIC FEE
3 Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) PLUMBING PEE
V O Lender's Name
LL Ladars Aaamss QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE O.o
U is ocelli.I agrehacomply with
city
ynd county
nordinances
a infnmutlon I '� FEES PAID:
4 ctinglo agree to complywilh andtyandrountyodmprese sal state lam PERMIT ISSUANCE
1- W city to a terup ingcomtmcilon,and hereby opertyorinrepresentatives o(thh
h' Z city Wente.to the,inde-rento dpropertyid the Cit purposes. ALTIIt Oft ADDTO MECH. Date Receipt#
_ (We)agnea t,jade,Indemnity an d keep earthen the City o Cupertino
agalmtllablBtlae,judgments,wrtsand expenses whkh may In an ayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
egebutsa'd asequence of the granting of this per it' CONSTRUCTION TAX
c ya�a '3 / /'t 6 AIR HANDING UNIT(OVER 10,000 CFM)
Sigrum .f pplicant'/Conntr✓adoor Date L V EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE �L
Will the applicant or future building occupant store or handle haeardous HEATING UMT(T0100,000 BTU) tf/ra Date RCCfI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Health and Safety Code Section 25533(a)7 HEATING UNIT(OVFR 1M,"BTU TOTAL:
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RERD) ISSfJA[yGG'DATE
which emit havdous air contaminants as defined by the Bay Arca Air )r�)s C/('j�1�1�lf
Quality Management District? BOILER-COMP(31111 OR 100,00)BTU r UV I
4 4Yes Sus BOILER-COMP BTU l' y 1990
have read the M1aza Safety
materiae 125505, 5533underChaptera6.95Of 111
the California I Iaxith&Safety Code,Sections 25505,25533 and 25534. I
understand that if thebullding does na curmntiy have atenanl,that ithmy NEW RESIDENTIAL MECH. SQ.IcI'. n
responsibility to notify the occupant of the requirements which must be and City(If r1mortA
prior to issuance of a Certificate of Odupanry.
Owner or authorlaed agent Data ISSUEDBY:4 w �UUeG�
TOTAL:
OFFICE COPY