19657 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES'-,USE'BALL'POINT,PEN ONLY • •''
Building Project Identification .{-. - PERMIT NO.Building Address:
ny rh7
Ownere arts: , Phone: - A
51�k}N Kb Pi�•: ` 'CITY OF CUPERTINO-BUILDING DIVISION.' . a
cavo- raN APPLICATION/ PERMIT Z'--�3 qa•-'
Arc en/En blog Lk.No .BUILDING ELECTIUCALnL BING MECFIAMCAL - CATEGORY - - CONTROL Is .
g ser
,a ,Q'rr .:t n 1ELECTRIC PER]NITiE 4,('lt yFEE 4 tr, BU[LDING4PERMITINFO
Ad��A2474" V/UVJ PERMIITISSUANCE' " P, � ' •.
LICENSED CONTRACTOR'S DECLARATION '
I hereby affirm that l am HcenseE unAer provisions of Chapter9(cammem, APPLIANCFSRESIDENTIAL JOB DESCRIPTION dion7 )ofavisi=3ofthe Ruslnej..ndP fesalon.Cods,andmy � � � ."
license Is in full force and died. PANGS - c�('�
License CWLk
js ' .p LIP TO 2DU a LU T P-62
Dale - Contractor -
"ARCHITECTS DECLARATION 201-I 000 AMPS
p X I undan
erstd my plans shall be used as public records. OVER I ODO AMPS SQ FT FLOOR AREA $/SQ FC.,-
❑O 1
'SIGNS ELECTRICAL
Licensed Professional - - ' -
6au�� OWNER-BUILDER DECLARATION d'• SPDMALCIRCUITMLCI hereby '
0
0 .,owingraffirm son.(hatlamexemp[fromthe Contrtoore Licenje Uwfor the
III 0 O-p� `following reason.(Section 7Ri1.5,Rualners and Proteselons Code:Any city or - '
OzW ORPOLE I
muntywhlchrequires aper tWcmutmd,altegimpmve,demolish,ormpatr P No
TEMMETER .
<`'O "'[ . -
.i any structure prior to its issuance,also requires the applicant for such permit to
5 Ym POWER DEVICES J
F�rC file a signed statement that he V licensed pursuant to the pon 7000) of Ne '
Q$µ,
Contractor's License Law(Chapter9(commencing with Section Divi- - VALUATION
to SWIMMING IDOL ELECTRIC
theri.Wsfthe thealleedexemption. Any violationthat f exempt therefrom and r
p, the boats for the alleged exemption. Any violation of Section ect m re any OUTLETSSWITCHESFIXTUREB i -
applicantforapermit$500).subjects the applicant to dull penalty of no[nnrethan
(� five hundred dolowner
of he pr.
(c` �I,as owner of the property,or my employees with wages as their,sole NEW RESIDENTTAL'ELECTR- BQ}T. .STORIES TYPE CONSTRUCTION
compensatlon,willdothe work,and thestmdure b not intended or offered for ,
Osale(Sec.7044,Business and Profession Code:The Contractors License Law
$ 'docs not apply to an owner of property who Wilds or improves thereon,and
'.. ,.. -hat each OCC.GROUP RES.UNITS who does sets am net
edorough his own employees,locavepr,theb ilding or
improvements are not intended orot(ered fonak.IQhoweveq ilderwdl have TOTAL:
ImprovemenHasold within oneyearofcomplelion,the oweri-bullderwillh a
t rdea of provingthat W did notbuild orimprove for purpose QTY. `PLUAIBING�PERMIT „ .tFEE'`
.Pco Q 4 . - FLOODZDNE` - APN .
ac as Domer of theproperty,am exdusiv s Business
and
with licensed Code: - - - '
1teL�J Y B - PERMIT ISSUANCE �9.
The Contra to construct the project(Sec.7004 Business and Professions Cade:
.t The Contractor's impr'j License Law does not apply to an owner d propertywho ALTER-DRAIN&VENT-WATER(EA)
Wilda lir improves thereon,and who macrosis for each p(ojeds with a y ,
c tadorexemtunder Sec to the Contractor's Llc&PLaw. .''FEE.SUMFEE,5 ;
q¢{ BACK FLOW PROTECT.DEVICE ..
1�I am exempt under Sec. B &P C for this reasonOUTSI
- DRAINS FLOOR ROOF,AREA,COND.• SANITARY t" ,Y_.N_ '
••. Owner " Date - - RECEIPT R
-WORK MAN COMPENSATION DECLARATION FIXTURESw PER TRAP SCHOOL TAX Y_ N'
❑I hereby affirm that I have a certificate of consent mself-Insure are . ' RECEn T If
cerdfinteofWmIaca Compensation Insurance or a certified copy thereof(Sac. GAS EA.SYSTEM-]INC.4OUTLETS PARK FEE Y N
3800,lab C.) RECEIPT p
Polity M GAS EA.SYSTEM-OVER 4(EA)
BUILDING DI VISION FEES
[�Cretitled copy hereby famished. - CREASE/INDUSTRL WASTE IN PLANGI-IEGIC FEE
❑Certified copy R filed with the city inspection division.' - -
-CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID -
COMPENSATIONINSURANCE -
' (Chissedianneed not hecompleted l(theperMt bforonehundred dollars SEWER-SANITARY-STORM EA.200FT. Date aRecei t#
($100)or leas.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I osmiylhat in the performance of the work for which this permit is issued,
I shall not empin anylrenner eo as to b bled to the WATER SYBTEM/TREATING' ,
Workera;Com a off if Its Date __7�Jv� - Z�CZ PAID '
'Z Z'. Applicant Mis_p_—_ NEW RESIDENTIAL PLMB. SQ.FT. Date ,Reeel t#
O NOT[C I A T:If, I n t Certificate of Exemption,you
.F should become subfed tothe Ooriorra pereation provisions ofthe Labor - .a. TOTAL:
N Cade,you moat forthwith comply with such provisions orthis permit shall be
W > deemed revoked. BUILDING FEE
CL G CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Z I hereby affirm that there is a mestmdlon lendingagenryfortheperform TOTAL i r ELECTRIC FEE
-am of the work for which this permit is Issued(Sec.3097,Civ.C.) - ( � '
V O- ' i<ndere Name - - t. ;,4 PLUMBING FEE' l�k�L"a0
LL F. Lender'sAaareaa - QTS:o' ;`M1;CHANICAL•''-PERMiT,, `.t?FEE'i. MECHANICAL FEE
OO leertifythitlhaveendthisepplicationand statethatthe above information
1 iscorred.I agree to complywith all city and munty,ordinances and state laws PERMRISSUANCE FEES PAID:
} relating to building construction,and hereby authomm represen[ativeaofthe; -
•F N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.;
Z -
.(We)agree to jade,indemnify and keep harmless the City of Cupertino Datti Recei P[# -
V against 11 Iltle,j.dgmenro,costa and expenses which may In anywayacrrue AIR FIANDLINC,UMT(TO 10,000 CFM) ', SUBTOTAL:
.gains al conequet the granting of this permit
41
' AIR HANDLING uNIT(OVER 1a,000cru) � CONSTRUCTIONTAX
g rco pplicant/Co ractor / Date EXHAUST HOOD(W/DUCT) _ CONSTRUCTION TAX-PAID:
HAZARDOUS MA .RIALS DISCLOSURE
Will the applicant or future building omupan[store or handle haiardoua HEATING UNIT(TO 100,000 BM Date, - R2CeI [#
material as defined by the Cupertino Municipal Code,Chapter9.12,and the.
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) ;..,TOTAL: q,e%
Yes . N No
. Will the applicant or future building occupant use equipment ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as deft ned by the Bay Area Air ,
Qua llty Management District? , - BOILER-C6MP(31I11 OR 100,000 BTU) j /(.
Pay
I�""7I No;
4have read the hIur a materials requirements under Chapter 6.95 of '.BAILER-COMP(OVER 100,000 BTU) : .
'the California Health&Safety Code,Sections 25505,25533'and 25534.I T.
understand that if the building does not mriently have atenanL that it is my NEW RESIDENTIAL MF.CH:• SQ.FT. Cit., r,� fsa—grflrv( '
responsibility to notify the occupant of the requirement which must be met "'
' poor to issuance oto Certi(Imte ofOmpanry, Z _�
Owner or authorized agent, r, Date, ISSUED RY:"'��
TOTAL:
OFFICE COPY'