19897 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build].,Project Iden ificatian PIRMRTNO.
Building Ad ress,o L4ti e t yo 19897_
�A(�� C4 �so
me. Phnn .
neva a ,z x, CITY OF CUPERTIN6BUILDING DIVISION
on�,�or'• aces: af/ Lie.No: APPLICATION /PERMIT
'!1z Lk ,J o so BUILDINGELECTRICAL-M I BINGMMC MCAL CATEGORY CONTROL#SJ7 1']-
AmMtect/En,,ni: Lic.No: •J
K kA QTY ELECTRIC PERMIT FEE BU DING PERMIT INFO
Address: + PERMITISSUANCE .�,OO �I a f�
R
LICENSEDC NTRACTOR'SDECLARATION 1�1
I hereby affimnthat l am licensed under provisions of Chapter9(commmc- APPLIANCES-RESIDENTIAL JOB DISCRR'IION
'ngwlth5 ton7000)of Dlvisi=3oftheBminessand Pmfes maC,.ode,and my
license la In fuB(eye deffM. PANGS
Liconsc Class CS �Licp
Date '3-2C�ContnRor Ng CAVA—
ARCHITECT'S DECLARATION 2014000 AMPS
�V I understand my plans shallbe used as public records. OVFRIODOAMPS SQ.FF.FLOOR AREA $/SQ.FT.
O
�j Licensed Professional SIGNS ELECTRICAL
�-Z OWNER-BUILDER DECLARATION SPECIALCMCUJ MLSC
� thereby affimn tlutlam exempt(romthe Contractor'.License law lm the
70 F. following reason.(Section 70315,Business and Proresmore Code:Any city or TEMP.METER0 LE AA I
county which requires a permit to mrutruo"ter,improve,demolbh,or repair
q p�j anysimct mpeortoinhmance,ahorequlnatheappllcantforsuchperMtm yVFRDEVI
E filea signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of DivI g y�� VALUATIO�
O cion 3 of the Business and professions Code)or that hehexempt tnerefromand
a G 5 the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWI AF5 6_ V{/ rl 1 O
applicant for a permit subjects the applicant to a civil penalty of not more than `J
five hundred dollars(5500). NE RES1D AL SQ STORIES rTYPECONSTRUC'I'ION
❑I,as owner of the property,or my employees with wages as their sole
compensation,will d o the work and the structure b not intended or offeredfor
Osale(Sec.7044,Business and Professions Code:The Contractors Licence Law
�$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UNITS
c. whodoessuch work hinseB orthrough hisownemployees,provided thatsuch
improvements arenot Intended oroffered for sale.Jf,howevegthebulldlngor TOTAL:
i proverrant hsold within oneyearofcompletlon,the owner-buRderwlll have
t rden of proving that M did not Wild or Improve for purpose of sale.). QTY. UPD
MBING PERMIT FEE FLOOD M'. APN
LI,as owner of the property,am exclusively contracting with licensed PERMITISS ANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who AL -DRAIN&VENp-WATER(EA)
Wilds or improves thereon,and who contracts for such projects with a
gBl3actor(a)licensed pursuant to the Contractor.License Law. BACK W PROTECT.DEVICE FEE SUMMARY
c l_I I am exempt under Sec B k P C for this reawn -
DRAINS- R ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT#
WORKMAN COMPENSATIONDECLARATION POOVRFS
PER SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of consent to self-Inure,or a RECEIPT'#
carrtlfiate ofWorkeri Compensation Insurance or a certified copy thereof(9ec. GAS EA.SYSTEM
UTLI:-CS PARKFEE Y_ N
3800,Lab C.I
RFLEIT p
Policy# GAS EA.SYSTEM-OVER d(EA BUILDING DI VISION FE FS
Com any
[1Centified copy h herebyfamished.thcity
GREASE/INDUSIRL WASTE R PLANCHECK FEE
❑Certified copy h need with ens ny wpectlon awhmn.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID-
COMPENSATION COMPENSATION INSURANCE SEWER-SANITARY- EA.200FT. DatC RCCCI t# a
(Thlssectlon need not be completed lithe permit h forone hundred dollars
($100).,In..) WATER HEATER VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of the work for welch this permit is hsued,
I shall not employ any person N any manner m as"to bbrco bjen to the WATER SY /.I.REAT[NG 3/ZIJ 9
WOrken'Cornpensatlon}��'c (GllfomW.Aate o PAID S C�
O Z Appuan1�Xe`_� a/F IAkx.a a-SSL fCabrbw enl_5.�- NEW RESID AL PLMB. SQFT. Date RCcei t# �r
Z O NOUCETO ICAM:ILafter.kingthb CenBlateoflaemptlon,you r //yy
should become subject to the Workers'compensation provisionsof the Labor TOTAL' -& OS
F y Code,youmustfodhwithmmplywlthsachprovhiomorthhpem tshallbc BUILDING EE 9.&0
9 deemed revoked.
LLI — CONSTRUCTION LENDING AGENCY SEISMIC FEE
EL G I herebyafflrmthat there is a construction lendingagency forthe perform. TOTAL: ELECTRIC FEE .OU
� Z anoeof the workforwhichthh permit is Wued(Sve.3097,Civ.C.)
Q0 Lenaera N.me_/1 PLUMBI
LL F Lenaers Addre QTY. MECHANICAL PERMIT FEE MECHANICAL FEE OD
OW Icenlfythatlnavereadthbappllatlonandstatethattheabove Nformation
(1. bcomect.Iagree to comply with allcityand countyordinanc,sand nate laws PERMIT ISSUANCE Z,D FEES PAID:
} relating to building construction,and hereby authorize representatives of this
1" Z city to enter upon the above-mentloredproperty for impectionpurposes. ALTER ORADDTO MECH. ,pp
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agairst liabilities, idgments,coasand expenses which may In anyway acme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL' _
agammsaia Ci in consequence ofthe am ingefthhpermlt TAX
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION
CONSTRUCTION TAX PAID:
I tum of AppRnlndor Date IXF3AUSTHOOD(W/DUCT)
HAZAZ ARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant Mercer handle huardous HEATING UMT(T0100,000 BTU) Date RCCCI t#
material as defined bytM Cupertino MunicipalCode,Chapter9.lZ and the
Ficalth and Safety Cade Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: ./JD
❑Yrs o
Will the appilcantbruture Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESIO) ISS16) JGFiDATE
which emit hazardous air contaminants as defined by the Bay Area Air �MIL�
Quality Management DI5ist1r�iNct? BOILER-COMP QHP OR 100,000 BTU)
4ha ereadthehaSsNouaomaterialsrequlrenrennunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) APR k D t9t$u
the California Health A Safety Code,Sections 25505,25M3 and 25534.I
understa nd that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify occupantmo
the occupant a the requirements which at be ret City of raoertino
2Tlor o issuaoce.f.Certificateofoccury.
?`20-Qd
Ow erm..fl me,niagent Date
TOTAL: ISSUED B�4
OFFICE COPY