19653 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE'BALL-POINT PEN ONLY . -
_. Building Protect Identification - - PERMIT NO.
BuildinBA '�3 cr; G-�:.. 19653
wnen _ Phone: APPLICATION SUBMITTAL p
00 Q DPAJ sy CITY OF CUPERTINO-BUILDING DIVISION'
•� Centre.N.,Pw APPLICATION / PERMIT
EL
Arc eR En ger.. " BUILDING- ECTRICAI;PLUMBING-MECIIANICAL CATEGORY CONTROL N
Lic.No:
3On `` t�tl 1 LECT2IC PERMIT ' ,`)FEE • '" BUILD,ING'PERMITlNFO ,• •�j;
'
PLUMB MECH
Address �S - - PERMITISSUANCE ❑, �'" �/� ❑e
+t LICENSED CONTRACTOR'S DECLARATION L J
[hereby affirm that larm licensed underprovlslon9 aChapter9(rommenc- MPLIANCESRESIDENTGL . -job DFSCRIPDON
Ingwith Section 70)0)of Division 3 ofthe Bus inessand Professions Code,aed my -
license la in fullforce and effect. - PANELS
License Class' LIC.# ••
Date" Contractor LM 10 200 AMPS
ARCHITECTS DECLARATION 301-1000 AMPS
q�q�uuQqq'" [understand my plass shall be used as public records, OVERIf100AMPS'.' " SQ FT FLOOR'AREA - $/SOFT.
Fl (� Licensed Professional - - SIGNS ELECTRICAL �.
G�6 OWNER-BUILDER DECLARATION ' SPECEEV
T/MLK:
ZE, � I herebyafRrm that l am exempt fromthe Contractors License Law for the ,
O following reason.(Section 7MI.5,Business and Professlons Cade:Any city or J
Z - TEMR POLE INST.
Pv� countywhnch requlresapermitlomsstmeq alter Improve,demollah,arrepair. '
nystructure prior toits Issuance,aIso requires the applicant for such permit to POWS
file a signed statement that he h,licensed pursuant to the proetsloss of the
3 w0 Contractors License law(Chapter 9(commencing with Sectl,n 7000)of Dlvl- SW1ML ELECTRIC
sion 3 athe Business and Professions Code)or that he is exempt therefrom and - - - VALUATION _
the basis for the alleged exemption. Any violation of Section 7031.5.by any OUTLETSSWHCHF, IXTUEES
applicant for a permit subjects the applicant to a civil penalty N oint more than - '
g5gc,GG five hundred dollars($500). NEW RESIDENTIALELECTR'
p �n ❑L as owner of the property,or my employees with wages as their sole SQ.FL 'STOIII6 TYPE CONSTRUCTION
compensation,willdothework,andthestructure Isnot intended or offered for
O sale(Sec.7UM,Businessand Professions Code:The Contracim's License Law
$ does not apply to an owner of property who builds or improves thereon,and
who doessochworkMmceBorthrough hisownemployees,provided thatinch ., OCC.GROUP I RFS.UNITS '
Improvements arena intended orotfered forsale.If,howneer,thebuldingor TOTAL
i provementissoldwithinoneyearufcompl&lon theownerbuiklerwlllh ve - ,L
V
trden Said of proving that he did not Sd or improve for purpose ofsak<), (7TY•:.
�o + `t,'Pj.[JMBINCi PERMIT P t "^t FEE:. ,FLOODZANE 'APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE -
contractors to mwtroct the project(Sec.7044,Business and Professions Code: I'Loc '' -
The Contractor's License Law does not apply to an owner of property who ALTER
builds or improves thereau -DRAIN&VENT-WATER(EA)on,and who contracts (or
ch,pWiects with a
ccnactcr(s)Bernal pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
LI I am exempt under Sec. B &P C for this reason
R AREA,GOND. SANITARY YIL' N
SIUL FEES
Owner Date DRAINS FLOG ROO$A
WORKAN COMPENSATION DECLARATION; RECEIPT k
M
❑I hereby affirm,that I have a certificate of consent to self4aure or a FB(TURFSPERTRAP SCHOOL TAX Y - N_
certificate ofW,rkere'Compensation Insurance a a certified copy thereof elec. - RECEB'T.p
3800,Lab C).- GAS EA:SYSIT7d4 INCACU7LETS PARKFEE ,Y_,N_.'
Policy N. - RECEIPT#
Cam any .:� GAS EA.SYSTEM-OVER 4(EA)' P' -BUILDING DIVISION FEES
�CertiRed ropy is filed hereby
the city
- GREASEANDUSTRL WASTE INTERCEPTOR ' PLANCHECK FEE '
- .''❑Certified copybfiled with the city lnpailon division. _
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
nc
COMPENSATION SEWER-SANIITARYSTO RM EA'200FT - ,Date Recei [#
(tBalose.) need not becompleted itthe permi[Is forone hundred dollars
($10))or less.) WATER HEATiR W/VENT/ ,ECTR ENERGY FEE Y. N
Iartti
ifythantheperformance ofthew.A forwhlch this permit is issued, Q —
I shall na empl,.am�erson in an,YJ,jr�sooer eo as to be..subject to the WATER SYSTEM/TREATING Q
Workers'Com1'�}9eyE-6n La (C I(q$Ala.Date - PAID
O Z NOTICE: P NEW RESIDENTIAL PLMB. SQ.FT. Date. Recei t#
Z O NOTICE Pik.. :it,aft e ma dngt la e orate of •:emptlon,you -
..F should become subject to the Workers'Com satlon provisions athe Labor - TOTAL:
� W' Code,you .at forthwith comply with such provisions orthlspertNt shall be
> deemed revoked. `n BUILDING FEE ,
W p corvsi'RucnoN LENDING AcwcY SEISMIC FEE.
CL Iherebyaffirmthat there baronstmRlon lendingagenry forthe perform- ELECTRIC FEE
7 Z ance of the work for which this permit Is Issued(Sec.3097,Cle.C.)' TOTAL
V O Lenders Name ., ,; ., PLUMBING FEE �'
LL F" ,` Lendcre Addreaa - - Q1,Y. `"' MECRANI PA4'P,FRMITI FEE,y' MECHANICAL FEE
O W (certify thatl have manthisappliwnonand statethattheabove information
1 correct lagreeto complywith all tltyand rounty ordinances and state lawn PERMITISSUANCE
>6FEE$PAID: ,
relating to building construction,and hereby authorize representatives of ld.
H 2 city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. c,
(We)agree to save,indemnify an d keep harmless the City of Cupertino ", Date Receipt#
against liabilities)udgmade,costsand expenses which may In anywayattme - AIR HANDLING UNIT(TO 101000 Cr M) SUBTOTAL: -
against Cit In consryuen ftbe gra rating of this permit. .� _
2' AIR HANDLING UNIT(OVER 10,000CFM) '1 CONSTRUCTIONTAX
g re pplirant/C tractor I Dare EXHAUST I TOOD(W/DOCT)'.I - 11 CONSTRUCTION TAX PAID:
HAZARDOUSM [ALS DISCLOSURE
Will the applicant or future building occupant store or hand to hazardous HEATING UMT(TO 100,000 BTI, Date-Da .` '
nuorhifas defined by the Cupertino Municipal Code,Chapter 9.12.and the Recel t#
Ilealthand Safety Code Section25532(a)7 HEATING UNIT(OVER 100,00)BTU) - e-n .,TOTAL:
❑Yes - MN. � _ _
Will the applicant or future building occupant use equlpmen[ordevices VENTILATION FAN(SINGLE RESID) ''I$roUANCE DATE
which emit haeitdousair mntaroinants as defined by the Bay Area Air - -
QualityManagementDistrictla BOILER-COMP(3HPOR100,0(p BTU)
?yes
4 No
have read the;azar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 2555,25533 and 35534.I • S y
understand that if the buildingdoes not currently have a tenant,that it is my, NEW RESIDENTIAL MECH. SQ.Ff.
reap,ssibility to notify the ompantof the requirements which most be met
prig to issuance of a Certif cafe o(Ocapanry.
Owner or authorized agent Date - -
TOTAL: �7. ISSUED BYL+C' �L�ll$E..
' C—
OFFICE COPY
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