19654 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES—USE BALL POINT PEN ONLY
Building PrWe t Identification PERMIT NO,
Budding Address: -
z�oC� 1965.4
wnero arr+n: -
Phone: -
CITY OF CUPERTIN6BUILDING DIVISION
• APPLICATION / PERMIT. 2 — 13-- q0
BUILDING-E TRICALPLUMBINGMECHAMCAL CATEGORY CONTROL X
Architect/Engineer. Lk.No:
' - ' t• - " - i .I V);,,BUILDINOtPERMIT INFO
/ tQN ,` 4ELECTR[C'PERIv11T I FEC .
Address:/ 1 7A— A ezi �� • . P RMITISSUANCE '• ❑ .. .❑ ❑
MCF.ASED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions olChapter 9(mmmene APPLIANCES-RESIDENTIAL JOB DESCRB'1'ION
ingwlth Sectlon 7000)of Dlv(slon3oflha Ruslnessand ProlesslonsCode,and my
-
license I.in full force and effect. PANELS
License Chan Lic.It
Date Contract. UPT0200ANTS
ARCHITECPS DECLARATION 201-1000A.MPS
WZ Iundentand etypbnsshallbeusedaspubNemccarde OVERIODOAMPS SQ.FT.FLOOR AREA f/SQ.Ff.
CO
E Licensed Professbnsl SICNSELECIRICAL
OWNER-BUILDER DECLARATION r SPFGIALCIACUIT/MISE
Iherebyaffirm that Is.exempt fromthe Contractor's License Law for the
p qqq following reason.(Section 7031.5,Business and Professions Code:An cit r
county which requires a permit to construct,altcp Improve,demolish,or repair TEMP.METER OR POLE INST.
any stmctu re prior to its haus nee,also requires the applicant for such permit to
OV file a signed statement that he is Iker sed pursuant to the provisions of the POWER DEVICES
�u, Contractor's License Law(Chapter9(commencing with Seetion7")ofDivi.
OQ ei..3.fthe H.s.essand Pmfemicro Code)orthathelsexemptihemfmmand SWIMMING POOL ELECTRIC _ VALUATION
65--tt the basis for the alleged exemption. Any violation of Se tion 7031.5 by any OUTLE765WITCHFS.FIXTURES
• applicant fora permit subjects the applicant to a civil penalty of not mofethan
O five hundred dollars($500).
F1L,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL.ELE-CTR 'SQ.FT. STORIES TYPE CONSTRUCTION
� 7< compensatl°n,wlll Bothe workandtheatrudure boot intended or offered for -
sszO sale(Sec.it Bdid the
and thes C^de:The of Intended roffeelaw
I�jS$ does not apply to an owner of property who builds or improves thereon,and .00C.CROUI' RIS,LNITS
who does such work himself orthrough his own employees,provided that such
Improvements arc not Intended proffered for sale.lf,howevegthebulldingor TOTAL:
Improveent Bsold within oneyearofcomplMWn,thener-bullderwlli have
tl� mowurden of proving that he did notbulldorimproveforpurpoceofall.). QTY,' 1,", PLUMBJNG PERMIT" 1� FEE FLOO ZONNE APN
L L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ry-t eoO
matracton to construct the project(Sec.7614,Business and Professions Code: ' l <
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER 6:A)
builds or improves thereon, and who contracts for such'projects with a - "
11
c,t LIITactors)licensed pursuant to the Contractor's License Law, as' " 'FEE,SUMMARY. '1' +
LI I am exempt under Sec. B Is P C for this recon BACK FLOW PROTECT.DEVICE
OUTSID1Owner Dates - DRAINSFLOOR ROOF,AREA,GOND. . SANITARY Y N�
. - RECEIPT
WORKMAN COMPENSATION DECLARATION �.NRFS-PER TRAP SCHOOL TAX Y_'N
❑1 hereby affirm that I haver lrt rale of consent d pythsure,or a RECEIPT,
artifkab of Workers'Compensatlonlnsurance oraartillcd ropythemof(Sec. CAS EA.SYSTEM-1 INCA 3300,lois CJ t PARK FEE V— N_
Policy It GAS EA.SYSTEM-OVER 4(EA) R[:CER'f p
Com any BUILDING DIVISION FEES
�Certifed ropy b heed with furnished. CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy ls(Bed with the city imps tion division.
' CERTIFICATE OF I7(L'MPIDON FROM WORKERS' GREASETRAP - PAID '
COMPENSATION INSURANCE SEWFR SANI'PARV STORM EA 200Ff. Date RCC61 t#
Qhorlm.) need not be.completed If the perrtdt lsfor one hundred dollars
($1I artifyss.) WATER HRATF72 W/VENT/ELECTR ENERGY FEE Y'- N
IcertlfythM in the performance of the work for which this permit is based, —
I shall not o 'I. any rmn In any r so u to become subject to the WATER SYSTEM/TREATING
Workers C n o GII(o�t-yDal�
PAID
Q Z ApplicantONE1y RFS7DENT[AL PLMB. Da10 ' RBCCI INZ ONOTIC cop PLI AM:IL after kiI(-isof^oemptlon,You SQ.FLshould subject to the Worken'Ct ion provisions ofthe Labor - TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be
> deemed revoked. BUILD
jL — CONSTRUCTION LENDING AGENCY SEISMIC FEE
S lherebyaffirm thatthereba construction lend Ing agency for the perform ELECTRIC FEE
Z ance of the workfor which thlspermit Is lasted(Sec.3097,Cl,C.) TOTAL: (L.0 '�
00 Leader's N.ma—Z PLUMBING FEE
U. F Lender's Address I QTY. MECHANICALPERMIT;.;,'. FEE 3 MECHANICAL FEE
O WIadifythztlhavere.dthlaappllationanda thaltheabovelnf..tlon - .
b correct.Iagmeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>• IL relating to building construction,and hereby authorize representatives olthln
F N city to enter upon the above-mentioned property for Wpedlon purposes. ALTPRORADD'TOMECH.
? . (We)aMe to save,indemnify an d keep harmless the City of Cupertino Data Reeei til
V against liabilities,judgments,contsand expenses which may in anywayareme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag.iodtaftat�in mnugt rt9e o(the granting of this ertnit
/ AIR FIA NDLING UNIT(OVER 10,00 CFM) CONSTRUCTION TAX
g ore of Appllcarl/ ,ontracto +/ Date. EXHAUST IIOOD(W/DUCT) - CONSTRUCTIONTAXPAID:-
HAZARDOUS TERIALSDISCLOSURE
Will the applicant orluture building occupant store or handle hazardous 1-I1RATLNGUNTT(TO100,6301ITU) Date Receivtq
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Ilealthand Safety Code,Sect1on25532(a)7• HEATING UNIT(OVER 100,000 BTU) - TOTAL. .�
❑ Yes M No _
Will the applicant or future building occupant use equipment orde0m, VPN77LATIONFAN(SINGLERESID) I$$UANGE•DATE
which emit haeardoua akon
ctaminantsas&flobd by the Bay Area Alf
•
Quality Management Dbirid7 BOILPR-COMP DFN OR 100,DM BTU)
4Ye No
have madthebaza o. ma tonal,requirements under Chapter 6.95 of BOILER-COMP(OVQ2100,IXp BTU)'
the California Health&Safety Code,Sections 25505,25533 and 25534. 1.
understand that if the building does not currently have.tenant,that it is my, s NEWRFSIDFNTIALMECH. - SQ.IT. s 'Cii"I AG rgr,p
priormiissua te'.ofa theicteof Occupancy.requlrarante wbkh rwst be trent \2 ^�O IUn' '
prior to issmnee'bf a Certificate of Occupancy.
Owner or authorlrad agent Date - ISSUED BY.
TOTAL:
OFFICE COPY
i k