19658 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
Building Pm•ect Identification "" - PE"IT NO.
Building Address: ._
2 � -��.; �;�.'�-�•. - r 1.9658.
OwnerName: Phone: p
'CITY OF CUPERTINO-BUILDING DIVISION " Z. ,`.+�• aQ O.
,r Ceat sNa - Un.No: .' APPLICATION /PERMIT O ^4
�(� BUILDING-ELECTRIC AGPLUMBING-MECHANICAL " CATEGORY CONTROL#. ,
Arch / gineer. _ Lk.No:
,r r:t• 1:'• ,•,.-BUILDING PERMIT WPO` ',R•`
. QTYELBCT�2IC-PERMIT .lt s -.',tFEC t '.
PERMITISSUANCE _ �. - 0
LICENSED CONTRACTOR'S DECLARATION, '
I hereby affirm that l am Licensed under provisions of Chapter 9(rommenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
lnenseISection to.and
dieon3 oflheguslnessandl'rofesslonsCode,and my '- t
(cense lslns force and effect. PANELS '
License Claes' Lie#
Date Contractor —UP TO 200 NTS
- .'ARCHITECTS DECLARATION 2014000 AMPS
P 9O I understand my plans shall be deec retar
deed as publids. a OVER 1000 AMPS - SQ.FII FL RAREA - $/SQ.Fr.
d6 Licensed Professional ' SIGNSELECTRICAL `
6 w E7 OWNDECLARATION
DECL ' -
SPECIALCItCUIT/MLSC - ,
Ihereb amrmthction7 xem (romsa d Prefctor'sllcenee law(or the
2 O '� following reason.(Section 7 tto Business and Professions Code:Any dty or '
0� TEb1P.MECER OR POLE(NST. , "
G countywhsh requlresa psaiance,rovaWctIne.th,.proanystrucve,demoah,orenitto
q "le asignerepriorto te.ranita Issuance,also req pursuant to
provisions
of to P64VER DEVICES
LF5�O file a signed statement that he k Ikeneed pursuant to the provlsioru of the
W3" Contractors License Law 9(commencing with Section 7")of Divi- '
Cin SWIMMING]Y30L ELECTRIC
�0� sion 3 o the Business and Professions Cade)orthat he is exempt therefrom and VALUATION -
y the Weis for the alleged exemption Any violation of Section 7031.5 by any OUTLETSSWITCHESFI%TURFS
pis applicant fora permit subjects the applicant to a civil penalty ofect morethzn +
[ m five hundred dollars($500) - NEW,RESIDENTIAL ELECTR STORIFS� ";TYPE CONSTRUCTION
I,as owner of the properly,or my employees with wages as their sole SQ'T'
C ¢ compensation,will do the work,and the structure k not intended or offered for. -
❑ sale(Sec 7044,Business and Professions Cade:The Contractors License Law
$$ does not apply to an owner of property who builds or improves thereon,and. OCC.CROUP RFS.UNITS '
who does such work himselforthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.](however,the building or - TOTAL:
improvement is sold within one yearofcomplelion,the ownerbudderwill have _ ov—
tl nj_kunten o[proving that he did not build or improve far ur ose of sale 1 1
LJ L P R P purpose ) QT§::}- ,PLLIMBING$ER1141T 'l ,'."FEE:x - FLOOD wNE APN
as owner of the property, Se exclusively Business
ess acting with Ikeneed pFltMIT ISSUANCEi.
' The Contractor's
ronLWctthe project(Sec.apply
Business and Professions Code: �`�
The Contractor's Lkenee law does net apply tn aowner oI property who +n'
Wilda or Imprdves thereon,and who.rontracts'for each p(ojecta with a ALTER-DRAIN&VENT-WATER(piU
,0II.((actor(s)licensed pursuant to the Contractor's License Law, - ,d•" A {`.,FEE;$UMI1'fARY•:, y"x"�'a'
LJ I am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE
J OUTS 11) FEES
Owner .Date DRAINS FLOOR ROO$AREA,GOND. - SANITARY _i RECEIrf#
WORANCOMPENSATIONDECLARATION FIXTURES PER TRAP - - SCHOOL TAX Y N'
•. •❑[heKM
reby affirm that I have a certificate of consent to self-Insure,ora " 1 #
..RFLF]Ixf#
3800,Lab C.) S .
certificieofWorkers'Compernattonlneur5nmoracetlfledmpythercof(Sec. CAFA. WC.40IJTLEfS ' PARK FEE. Y_ T
Policy p r - , ' '' RECEIPT#
Com an GAS E- .SYSTEM-OVER4(EA) .,
C' Y BUILDING DIVISION FEES
Certfffed ropy I.hereby famished. - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy N filed with the city inspection division.
CERTIFICATE OF ECEMPFION FROM WORKERS' GREASE TRAP PAID
tiCOMPENSATION INSURANCE ' SEWER-SANITARY-STORM EA.200Ff. Date ROCe1oo
(fhisseaion need net W compleed If the permit ct forone hundred dollare
($100)or less.) „ WATER HEATER W/VENT/ELEC172 ENERGY FEE -Y N
I certify that In the performance of the work forwhich this permit lc Issued, ,
I shall not emplo rson In any Per e�hm� ubject to the WATER SYSTEM/TREATING -aZrkers'Gom s 11 d a7O Z. NOTTC nt � �1%�ik � NEWRESIDENTIALPLMB.__SQ.Fr. PAIDDat2 RCtPI t#Z OF4S�' ICAN�"F: f,a er d gthimption,youbecomesulfic.to the Workers'Comp ofthe labor TOTAL:
N Code,you moat forthwith comply with such provisions orthis permit shall beBUILDING 'E
j' deemed revoked. -
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
a (hereby affirm that there is a construction lending agency for the perfor ELECTRIC-FEE
M Z ance of the work for which this permit is Issued(Sec.3097,Civ C) IOTA[ �.
O O . I.endera Name x PLUMBING FEE'
LL F Lenders Addrcea .. - "t QTY, i.MECR_ANICAL'-PERMIT .FEE MECHANICAL.FEE - "
O W I certifythatl have read this appllratlonend smtethatthe abweln(ormatlon -
iscorrect.l agree to comply with all city and county ordinances and elate jaws IPERMTT(SSUANCE FEES PAID: ' -
1 relating tobuldingcomtruction,and herebyau[horizerepresentativesofthfa - - -
F—"W city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMFCH.
•(We)agree to save,Indemnify an d keep harmless the City of Cupertino DBte p CefPtN
..V against liabilities,judgments,roateand expenses which may in anywayaceres AIR HANDLING UNIT 10,000 CFM) "SUBTOTAL:
agains d sit, in mrsequja9ifithe granting oftMspern1 t.
'1 /r AIRHANDLING UMT(OVFR iflotalcrAo,: CONSTRUCTION TAX '
G / r
.Siglialsi
re of Appllcant/ oatractor Dae E%HAf15'r Hoop(W/DUCT)" ' CONSTRUCTION TAX PAID:
HAiZARDOUS TERIALSDISCLOSURE L
Willtheapplimmorfuture building ocmpantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCi IN
material as defined by the Cupertino Municipal Code Chapter,9.12,ana the: �y�
Health and Safety Coder.�Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) - �°'� ITTOTAL: �{JI/
- ❑Yes u No
Will the applicant orffium building occupant use equipment ordevices VGVrILATION FAN(SINGLE RESID). 'ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air._ - I
•
Quality Management District? BOILER-COMP(3HPOR100,6w BTU) - I "✓ r / 1✓_ - '
4Yes ❑No
havcrcadthe hazard...materla requirementsudrChapter6.95o( BO LHR-COMP(OVII10,000 BTU)
the Celifernia Health&Safely Code,Sections 25505,75533 and 25534.1
and ersta nd that if the Wilding does not currently have a tenant,that it fit my NEW RESIDENTIAL MUCH. SQ.FT. laltr
responsibility to noldythe occupant of the requirements which must be met - O `
prior to issuance of a Certificate of Occu ^L
pancy. 1 1��
Owner or authorized agent - Date , - 'l�sb l
" I I'O'rAL: ISSUED BY:ys-+l%C14z\W.r
• OFFICE COPY .