19822 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY ✓
Building Pro:ed Identification PF WT NO.
Building Adflms,: 19822s q
IIaO L /�'�DA-�f S/✓t/1-L
mance hone: APPLICATIn7779MIlTZ=A
CITY OF CUPERTINO-BUILDING DIVISION
Cent.tnr,wme: - uc.N¢ APPLICATION / PERMIT
• SVNO cie AI fG�Tr " BUILDINGELFiC7RICALI'LUMBING-MECIIAMCAL CATEGORY CONTROL
Amhitet/Engineer. Lle.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERWTISSUANCE
LICE NS EDCONTRACTORS DECLARATION mo
❑
IDI hereby affirrn that Tam licensedunder provisions
ofChaptcr9(commmc MPLIANCESRFSIDENTIAL JOB DESCRB10N
Ingwlth5diono )ofDW,ion3oftheBusmmandProlnsoaCode,and
my
license Is In fuB f9ge a?nd effect. S r�p� PANELS '
7 License Cla .�(rf_Lic.If �1 5 7 J 6 S , 7k
Date /o. Contnnor L
RC he SDE OVEWO AMPS
{Qq�Z 1 n nd�, M taedysp Dicta OV AMPS, �.FT.FLOOR AREA 5/eJQ.FT.
E PJ Llcen�sslga AGNS TRICAL
fn< OWNEReBUILDER DECLARATIONI hereby SPECIAL CUIT
owingrof@mthatlam31.5,Business fromthe Contractorns icenseCod:law fm the
0 9L following realm-qu to pea 1.5, and and Professions e=16h,y city or gFA1P.M LE I
F4 muntywhure riortoas pamittommtrquirestheaprovent fors ch,ormitto
O�� any atrvcturepdormlte Issuance,also regpursuaappBa.forsuchof permitto POWER DE'VT
�� file a signed statement that he V licensed pursuant to the provlsioro of the
w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIM 30� LC VALUATION slon3o(the Businessand Proressloru Code)orthat hebexem therefromand
the basis for the alleged exemption. Any violation of Section 70315 by anyOUTLE155WI XrURFS V+ y,
QOS applicant for a perend"ubjects the applicant to a civil penalty M not more t ban ma,� v V • G 0
5� five hundred doll..(§500).
NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPE CONSTRUCTION
❑Las owner of the property,or my employees with wages there sole
�7a wIs&.tion,wut,louheworkf.i. sCde:Te isnot Contractor or License Law sale(See aptly to ainowner fpropeom who
Wild.d.or iropme.Llceme law
�js$ docs net apply toanowoer orp rough whonorimproovided eortand OCC.GROUP RFS.UNITS
who does such work tinteff or ndedoroughhhowals.1(employees,p r theb thatsuchG b
improvementsarcnot Intended earofco forsale.If,howevep deer ill have TOTAL:
improvement is sold proving that one he id ove build or ire the a for purpose
of sshave
tl{,);urdenof wnerof the popeidnMbWld orlmp contracting
with liens QTy. PLUMBING PERMIT FEE
L,f L a,owner of the property,am exclusively contracting with licensed F100D ZDNE APN
PERMIT ISSUANCE
contractors to construct the project(See.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
builds or improves thereon, and who contracts for such ptpjet, with a FEE SUMMARY
c9nitactor(s)licensed pursuant to the Contractor's License Law. BACKFLOWPROTECT.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 N
WORKMAN COMPENSATION DECLARATION FLXTURTS�PER TRAP SCI'IOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to eel(-Insure,ora RECEIRT N
eenifiateafWoromV Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N
3900,Tab CJ RFL=N
Policy N GAS EA.SYSTEM-OVER 4(FA)
Coommpany N BUILDING DI VISION FEES
11eiGFiBed copy is hereby filed
the city
GREASE/INDUSIRL WASTE INTERCEPTOR - PLANCHECKFEE
_rL�J4Cenlfied copy b flied with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SPORM EA 200F7 Date Recei t#
(This section need not be completed if the pernat a for one hundred dollars
(SIW)or IoO) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that tribe performance of thework for which this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATERSYSIFM/TREATING
Workeri Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL I'LMB. SQFI. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you
N should becomasubjeet to the Workers'Compensation provision,of the Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall be, BUILDING FEE
W deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE Q
Il Z I hereby affirm that there u a rotutrution lending agency for the perform- TOTAL: ELECTRIC FEE• pfd
D �rce ufthe work for which this permit is issucd(Sec.309],Civ.Q ELECTRIC EEE
00 Lcnder's Name
F 1.endces Address QTY. MECHANICAL PERMIT FEE
LL O MECHANICAL FEE
Icertifythatl have readthisappliationaM statethataheabove information
O W isc.mi1agere to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} a relating rebuilding mrutractlon,and hereby authorize representatives of this nr/a� L.7 ���
F N city to enter upon the above-mentioned property for inspection purpose,. ALTER OR ADD Ila MECH.
2 Date Receipt#
(We)agree to save,Indemnity an d keep es which
the In a y Cupertino
V
against liabilities,Judgments,costaend expenses which mayln any way accrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL: J
against Old City in con of ages nti permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
rotor ate EXFTAUSTHOOD(W/DUCT), CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DIS SUR
Will the applicant or future building occupant set re or handle hazardous HEATING Utxgi(TO t00,W0 BIIl) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ilealth and Safety Code�+.-Stection 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea u No
Will the applicant or future building occupant use equipment or devices VEMDLATION FAN(SINGLE RESID) y ISSUANCE,BATE
which emit hazardous air contaminants as defined by the Bay Area Air F w-
• Quality M.wgc..t D'alrit? BOILER-COMP OFB'OR 100,"BTU)
4hvesread the havagoomaterlalsrequlnmentsunder Chapter 6.95of 30ILERCOMP(OVERI00,000BTU) , blilll� U7J`t)j
the California Iimlth&Safety Code,Sections 75505,75533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RGSI DENTIAL MECH. SQ.IT.
responsibility to nor l(y the ore pant of the requirements which must be rrxl Clt.r P` rr1^grtlnv
priorto lssu mot a Certificate tOccupancy. 1
OwneTOTAL:rorauth da Date ISSUEDBY:Nc
OFFICE COPY