19648 (2) APPLICANT TO FILL IN INFORMATION-WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Pm'ecf Identification - PERMIT NO.
Buildinj�bMresa: -
� F 2 � - .+1960
+wnera Name: - - - o Phone: A
PPLICA LION SUBMITTAL D7
1 +F CITY'OF CUPERTINO-BUILDING DIVISION c7 '
C. er'.Name: - ^, Lie.Nu: APPLICATION / PERMIT'`
IA A-1— r BUILDING-ELECTRICALI'LIJM8ING- CATEGORY ,� CONTROL N
A tett/Engine r: Lic.Na MECIAMCAL
i 2 .. 4 ei 4 t
,QTY+++ >< '```E4ECTRTC DERMA' X, tt �,FEE is '"` +;;rBUILDING PERMII';INFO,
Address: �+ PLRMITISSUANCE ,• i +
LICENSED CONTRACTOR'S DECLARATION ,t �' IN
]hereby affUm that lam licensed under provWons of Chapter 9(mmmen AI'PIJANCLSftESIDENTIAti" FOB DESCRUMON '
fngwith Section 7000)of Dlvision3 ofthe Busimssand ProfessionsCode,and my -
lin se le in fug force and effect. PANELS
License Glass LIe N 1— LIP TO 200AIZ!q � � - 'C-r
L to Gontranor -
'.ARCHITECTSDECLARATION 201-1000 AMPS
`K ZO IunAerstand brie shag be used as public records. OVER IOOOAMI'S SQ
O _ my P P - SQ.FT.FLOOR AREA S/, .FT.
�j
Licensed Professional 't SIGNS ELECTRICAL _
6 ` OWNER-BUILDER DECLARATION SPECIALCIRCLBT/MISC `
zFO' � Thereby affirm that Iam exempt from the Comructor's License Law for the -
O 2 t- following reason.(Section 7MI1 5,Business and Professions Code:Any city or TEMP.METER OR POLE]NST. '
F�q� county which requiresa permit rocoustmet,alter,improve,demolish,ormpalr
4 5.0 anystrvcture priorteltstmuance,also requiresthe applicant foreuch permit to POWER DEVICES '
6p�O 4Fl V .file a signed statement that he is licensed pursuant to the provisions of the -
Q31"� Contractors License Law(Chapter9(commencing with Section 7000)of Divi SWIMMING POOL ELECTRIC
3 ofthe Business .
cion and Profmaiiom Code)orthat he is exempttherefromand VALUATION
the basis for the alleged exemption Any violation of Section 7MLS by any
o appllcantfora permit sub)ectathe applicant to a civil penalty elect morethan OITILETSSWITCHESHXIURFS
five hundred dollars(S500) �.
.. OI,as owner of the property,or my employees with wages as their sale - NEW RESIDENTIAL ELECTR__SQ.rE STORIES TYPE CONSTRUCTION
zq�¢' compensation,wllldothe work andthe structure Is not intended or offered for
F❑ sale(Sec.7044,Business and Prufeasions Code:The Contractor's License Law -
$ , does not apply to an owner of property who tiuilds or Improves thereon,and - -
who does suchworkhimself orthmughhis own employees,provided that such OCC.CROUP FRCS UNITS t
.. improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL: -
i provernentlssold within oneyearofcompletiogtheowner-builderwilihave
-
try_p�+rdenofIo,wmgthathe did not build or Improve for purpose of sale) Qjy, �.. t;'PLU111BING,PERMIT ,y t' ;FEET; FLOODPANE APN
L�L as owner of the Property,am exclusively contracting with licensed . PERMIT ISSUANCE UI ,O
contractors to consumer the project(Sec.7014 Buslnces.ed Profc.I..Code: ,.The Contractors License Law doe.nor apply to an owner of property who ALTER-DRAIN VENT-
Wgda or Improves thereoM and who contracts for such plojecte with a WATER fCA>
�I ctor(s)harmed pursuant to the Contractor's License Law, %'t+'•+ 't 'FEE�SUMKIARY,'t' b
I am exempt under Sec. B&P C for this rcmon BACK FLOW PROTECT.DEVICE
Owner Date - DCUTS I DE FIT—q
RAINS FLOOR,ROOF,AREA,LAND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATIONRECEIVE It
❑ mrt
�u I hereby affirm that I have a ilimte of consent to self-insure,or a FDCTURES PER TRAP ' SCHOOL TAX Y N_
certificate of Workers Comperuation Insurance ora rertl(led cnpythereof(Sec. RECEIPT N
3800,Lab C.) GAS EA.SYSTEM-1 INC.4 OUTLETS - PARK FEE Y N `
Policy N RECEIVE M
Com any - GAS PA.SYSTEM-OVER 4(EA) v" .'BUILDING DIVISION ITES
Cert End ropy Is herebyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�Certlfied copy Is filed herebyifimust d.lrepenlon divlslani
X
CERTIFICATEMENS FMI'TI NS FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE' SEWER SANITARY STORM FA'200FF Date RCIY'1 t#
(This section need not be completed If the permit Is for one hundred dollars
(81I mmfyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y�- N
Irertify[hal in the performance of the work forwh�th.lfs permit is issued, —
I shall not employ person In any manner so suite
tome mbject the -
WorkereCompan wof 'Id
pan
WATER SYSTEM/TREATING (1O PAID ..
O z Applicant 2 (/ny
Z O NOTICE Ie'AaP'L1 AVT:ILaRer kngrhis Certl41 Exemption,you NEW RESIDENTIAL PLMB. SQ.FE Date Recei t# -
fshould become subject to the Workers'Compensation Provisions of the Labor TOTAL:
N - Code,you must forthwith comply with such provisions or this permit shall be
W > deemed revoked. .. _ BUILDING FE
a CONSTRUCTION LENDING AGENCY _ SEISMIC FEE -
I hereby affirm that there is a oewtmctlon lending agency for the perform ELECTRIC FEE'
Z., anceofthe work for which this permit is Issued(Sec.3097,Civ,C.) TOTAL ' Q'�
V O Lender's Name - i .-t PLUMBINGFEE a CQ
LL H 'Lenders Addreea QTY: +{ MECHANICAL PERMIT •,:FEE';'t MECHANICAL FEE
O W d Icertifythat1havereadthisapplicationand..mthaHheabovelofomutlon -
1 iscorren.Iagreetocomplywithallcityand county ordmancesand statelaws _ PERMITISSUANCE FEE$jaA]D;
N relating to building comroction,and hereby authorize representatives of this - -
F U) city to enter upon the above-mentioned property for Inspection purposes. ALT ER OR ADD TO MECH. '
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino ' Date Rece1Ptif,
against liabilities,udgmenm,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL;
agafnste i� ' sequence oftJ t Ing of this permit. H
1rC� /YL`�if/r 7V AIR HANDWNG 11MT(OVER 10,W0CFM) CONSTRUCTION TAX':
ore fApplicant/Contrac r - _Date EXHAUST HOOD(W/DUCT) " CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA ISCLOSURE
-
Will theappleaut or future building occupant store or handle hazardous HEATING UNIT(TO IO0,000 BTU). Date -
materlalasdefined by the Cupertino Municipal Code Chapter 9.17,and the _ RCCeI t#.
Ilnalth and SafetyCode Seniors 25532(a)7 I!EATING UNIT 100,OW BTU) TOTAL: ,,G21
Vee No - ...
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE'DATE
which emit hazardous air contaminants as defined by the Bay Area Air �.,
• Quality Management District? MILER-COMP OIB'OR 100,0Ip eTU) LG-� T O 74
4Yea ❑n ice .l. J `9n
have mad the hazardous materials requ irements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Calffomia Health&Safety Code,Sections 75505,M533 and 25534.1 - /1!
u neterstand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIE ' SQd7T. - 'r�rj'Of CAM,*
rmponsiblllty to notify the occupant of the requirements which must be met
prior to Issuance ofa Certiticate o(Occvpanry. - .,
Owner or aulhorlud agent Date _,
• .TOTAL: ISSUCDBY:Q��
OFFICE COPY it