19491 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: /i p [3t�—T
gb&'3 ��k I//i Ila X06- /� O (/ 19491
O,aer'sName:
Phone:
Jus &Lf 4L- Ala raka-ll 2$5-96 CITY OF CUPERTINO-BUILDING DIVISION
cont , ame: zAPPLICATION / PERMIT GORY
BUILDING-ELECTRICAI-PLUMBING-MLCHANICAL CATEGORY CONTROLM
Architect/Engineer. 0 Lie.Nrx
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addeo: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmlamlicensed heBusimvvslodpmfesomsChapter 9 e,an nc- AI'PWANCESRESIDENTIAL ]OB DPSCRIIPIION
Ingwlth5ect1on7000)of Dlvblon3o(the Buslnnsand Proles one Code,and my
license b In lu rq}rad d(ect. PANELS f �.(�j�
Date C ss LI/ LIC M 1'� V ' ' '✓��
Date I CHInc:r �/(� —UP TO 2DDAMPS
ARCHITECPSCLARATIO OVER
AM
at OO 7. I understand my pions shall be used n public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/9Q.FT.
COC
Licensed Professional SIGNS ELECTRICAL
<<w OWNER-BUILDER DECLARATION
t; �d SPECIAL CI(CUIT/MLN A
I herebyaffirm slut I am exempt from the Contractor's License Lawforthe D
Z t— 7.
p following reason.(Section 7!315,Business and Professions Code:Any city or
7 f., TEMP.METEBov6LE INST.
�Q
county which requires permit toconstruct,slice improve,demolish,or repair
Qany structure prior to its issuance,also requires the applicant for such permit to POVIERDE S
E U file a signed statement that he is Bcewed pursuant to the provisloru of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Div'- G IDOL ELECTRIC A N
F,�OS sion3ofthe Buanmand Profmiow CMe)orthathebexempttherefromand '
the basis for the alleged exemption. Any Wolatlon of Section 70315 by any O .IS SWITCHESFIXTURFS 1
QS applinntforapermitsubjedstheapph,..tt..dvilpewltyof..moretu.
foe hundred
wnerofthe pr). 'W RESIDENTIAL ELFCTR SQ.FT. STORMS TYPE CONSTRUCTION
Q c❑1,asowneroftheproperty,oche employees with wages r their sole
ompansatloo,Business workaestomwale: bnotntIntended o iofferedfor
$ ,O sale(Sec.apply
toa owner Profmions who
WildsThicor impoarmractor's Censerctrue law
[ $$ don notapply torn owner ofpwugh his onemporrmpwovidedthatand OCC.GROUP RES.UNITS
who domsuch erosworkhimself ed trough hisownemployee provided[hal such'
improvementsamnmithindneyearfcompletioroffered .If,howevegilder ill gorhave TOTAL: -
improvement Is sold within one year ofcompidlon,the owner-bullderwlll have
tryc-Is.ben of pmving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FLOOD TONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7010,Buanm and Professions Code:
The Contractor,License Law don not apply to an owner of property who pLq�(-DRAW&VENT-WATER[EA)
Wilds or Improve, thereon, and who contracts(or such Imajeits with a FEE SUMMARY
cocto(.)Iluwed pursuant to the Contractor.License law. BACK FLOW PROTECT.DEVICE
If, 'noexempt under Sec. B &P C for this roan
on DRNS FLOOK ROOF,AREA, ND. SANITARY Y_ N_
Owner Dae AIRECEIPT I
WOR KHAN COMPENSATION DECLARATION FIXTURES PER TRAIT SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to cel(-Insure,ora RECEIPT#
"m cde.fWorken'Compensatl.n munnmporamgrtiflcdpcopythereof(Sec. GAS EA.SYSTEM-1 W .4 OUTLETS PARKFIT Y_ N_
Lab C.) aa_cuel�:.�i�a ( -P() RECEIPT#
Com any A /Y 'Ff/�C GAS EA'SY''TEht- VER4(FA) BUILDING DI VISI ON FEES
�Certmed copy is he furnished. CREASE/IND LWASTE INTERCQ''TOR PLANCH[CK FEE copy is filed with the city Inspection division.
CERTIHCATE OF EXEMPTION PROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEW SANITARY-STORM EA.XpF I'. Dd[C RCcel [#
(This section need not be completed tithe permit b far onshundred dollars
($100)orleu.) W HFATERW/VENT./EI.ECTR ENERGYFEE Y_ N_
I certify that in the perfomunceof the work forwhich this permit b Issued,
1 shall not employ any person In any manner,o as to become subject to the ATER SYSTEM/TREATING
Worker:Compensation Laws.(California.Data
PAID
OZ NOTIao` NEW RESIDENTIAL PLMB. SQ.FT. Date Recel t#
ZU NOTICETOesub APPLICANT: orkem'fter komperation poisons of thcatrof e
should become subject to the Workers'Compensation provblons.(the Labor TOTAL:
WCC N Code,you most forthwith comply with such provisions or this permit shall be BUILDINGFEE
j deerrcd revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL
Ihereby.Mrm that b a construction lending agency for the perform TOTAL: ELECTRIC FEE
Z ante ofthe work for which this permit s bsucd(Sec.3097,CIv.C.)
U O Indere Name PLUMBING FEE
F Lenders Address QTY. MECHANICAL PERMIT FEE
LL
U I certitythat l have read thisappliationand nate thetheabove in tion
,I MECHANICAL FEE a
O W scorers.l agreeto comply with all city and rountyordlnances and state laws PERMIT ISSUANCE �d FEES PAID:
(L relatingt.b ildi.g ronswcti..,.ndheeby..th.d .pre nitives of thio
N city to enter upon the abuwunxswtioned property for Wpeaion purposes. ALTER OR ADD TO MECH.
? (we)agree to save,Indemnify an d keep harmless the City.(Cupertino Date Receipt#
(..I wt liabilities,' d ts,costs and ex swhich ma Inn a ATR HANDLING UNIT 10,OWCFM)
Zmgr N gmen pease y ywayaearu SUBTOTAL:
ioatsa f)in coneryuence oRhe granting dthla peg�O /^a CONSTRUCTION TAX
oS l/7 AIR HANDLING UNIT(OVER IO,000CI:N)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE ^^��
Will the applicant or butane,
building occupant store or handle havardous HEATING UNIT(TO 100,000 BTU) 'DV Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safdy CMee Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yv. ,No
Will the applicant or building occupant useequipment ordevices VFNIILATION FAN(SINGLE RFSID) ,ISSUANCE DATE
which emit hanrd.us air roniaminaresas defined by the Bey Area Air
Quality Management District? BOILER-COMP(3111'OR 10BOW BTU) lam;
4Y", No y ��O
hayemail the ha a 7ousmaterials rcqulremensundcrCM1aper6.95o( BO LER-COMP(OVQ 13,000BTU)
the California Health&Safety Code,Sections 25505,75533 and 75534. IJ .c`f� VJ
understand that lithe building does not cuently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met �Ifmd of
rjfprior to issuance ofa Certificate of Occupancy. ��/5 _'? .t[IBO
Owner,r authorized agent Date ISSUED BY
TOTAL: QD
OFFICE COPY