19661 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ,
Building l'ea'se IdeIdentificationPEILMITNO.on
�a19661 .
'Building Address:
area Namen Phone: APPLICATION SUBMITTALA
HI
.� � CITY OF CUPERTINO-BUILDING DIVISION 2^I ^�
1p
come r Na Ne APPLICATION I PERMIT, l r
BOLDINGMMTRICA4PLUMBINGMEC UMCAI CATEGORY CONTROL p
ArchllM/Fs ne LIc:No, _
(i } { ' `' ' ,' P ' ,,.BUILDING PERMIT INFO;
er QTS ^ ELECT'IC PERMIT gFCE' - '
Address: A"l ~- PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
Iherebyaffirm that l am Bernard under provisions of Chapter 9(commene APPLIANCESRESIDENfIAL )OB DL ,IUPI ION
ingwith Soften MITI)0(Division 3 ofthe Business and Professions Code,and my
license is In(uB force and effect. PANELS -
LlanseClan Lie.A ['
Date Contactor UP TQ - •�� �'� S1
ARCHITECT'S DECLARATION OVERIOAMI5
q201-1 M
p 0 I understand my plans shall be used as public records. OVER 1000 AMI"'' SQ.FT.ILOOR AREA ,. f/SQ.FT'
OC
}a fJ Licensed Professional SIGNS ELECTRICAL' _ .
d�<wF OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC '
s, PI Iherebyafflrmthatiamexempt(romthe Contractor's Llcenm Gwforthe I .
od d following reason.(Section 7031.5,Business and Professions Code:Any city or TpMp METER DIPOLE INST. 's
P� county which rNuiresa permittocommuct,alley Improve,demolish,oreepalr
any structure prior to its Issuance,also requ fres the applicant for such permit to POWER DEVICES
M1 In file a signed statement that he is licensed pursuant to the provisions of the
40w . Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
W O sion3ofthe BuslnessandP (esslom Code)orthathekewmpttherefmmaad
Sn S the basis for the alleged exemption. Any violation of Stolon 71315 by any OUTLETSSW1TCIdFSF1kTURES
aP applicantfor a permit sub)ectsthe applicant to a civil penalty of not more than
five hundred delta.($500). NEW RESIDENTIAL ELECTRSQ.Fr. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sok
G .compensation,will do the work,and the stmeture is not intended or offend for
to(Sec 7044,Business and Profeashma,Code:The Contractors Llcerue Law -
$$ does not apply to an owner ofproperty who builds or improves therms,and t - _ - OCC.G'R•�OUIs RES;UMTS
who doessuchworkMmselforthrough hlsownemployees,provided that such
improvements are not Intended orof(ered forsaie.If,however,thebuildleg or TOTAL:
improvement lamld withinoneycarofcompidiom theowner-builderwlll have - .3 -
th men of proving that he did not build or Improve for purpose ofsale.). QTY, ..t',<"PLUMBING PERMIT.� •„t .',FEE t; FLOOD ZONE � APN
�I,as an,of the property,am exclusively contracting with licensed PERMIT ISSUANCE.
contmeoes to conabuct the project(Sec.70K Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT•WATER(EA)Wilds or Improves thereon,and who contracts for sua-pto)aa[e with a
oyl��ct r(.)Iicenmd pursuant to the Cont.dm'e License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
rl_I I am exempt under Sec. B k P C for this reason )1:IT I;s____
DRAINS FLOOR ROOF,ARG,COND. SANITARY Y N_
Owner Date '. RECEIPT If
• WORKAN COMPENSATION DECLARATION FIXTURES PER TRAP - SCHOOL TAX Y_'N_
❑I hemM
by affirm that 1 have a certificate of consent to sell-Insure,ora RECEIPT N
certificate of Workerd Compensation Insurance or a certified copy ehemof(Src. GAS EA.SYSTEMd INC.4OUTLETS PARK FEE Y N
3800,Isis CJ - RECEIPT N
Policy tl GAS FA.SYSTEM-OVER 4(FA) -
Cany - BUILDING DIVISION FEESom
❑Certilled copy N hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F. Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS". GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recai t#
(This section need not be completed lithe permit later one hundred dollars
(SIMI or len.) WATER HEATER W/VENT/ELECTR ENERGY PEE Y_ N_ '
I certify that in the performance ofthe work forwhlch this permit Is Issued,
I shall not employ any rector In any ser so as to become sub'ct to the WATER SYSTEM/TREATING COorkers'Compe ,awsof Cally �a.Date 2L'4! PAID
,O Z Appllant NEWRESID=ALPLMB. SQFT. Date ReCei t#
Z O NOTICE CANT;IL after nukingt c .erdflate of Examptles,you
should become subject to the Workers'Corr sat ion peavislom of the Labor TOTAL:
IN Code,you at four hwith comply with such provisions or this permit shall be -BUILDING
W ] deemed revoked. _
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
d G I hereby affirm that thea la a construction lending agency for the perform TOTAL: ELECTRIC FEE �r-
7 2 an.of the work for which this permit is Issued(See.3097,CIv.C.) - PLUMBING FEE cw
u O Lender's Name _t
IL I- Leeders Address QTY._ MECHANICAG:PERINIT••'• FEE' MECHANICAL FEE
U 1certlfythatl havemacithisappliratlonand statethatthe above information
O W iscorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
n' misting mbullding conslmction,and hereby authorize repersentativesohhla
(— N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date
? (We)agree to save,Indemnify an d keep harmless the City of Cu pratno RCCe1P4#
V
against liabilities,pdgments,cots and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,0DO CFM) SUBTOTAL:
aga Inst sa City in conaaluene a grant ing of this pa3. a - CONSTRUCTION TAX '
ew 7-49—
CONSTRUCTION
AIR HANDLING UNIT(OVER 10,000CIM)
si o A pliant/Contractor to aHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
WIIlthe applicant or future building occupant store orhandle hanrdous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chdptri 9J Z and the - r
Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: LelLf•�
❑ Yea NN. - .-, .. .
Will the applicant or future building occupant use equlpmnnl'or devices, VENTILATION FAN(SINGLE RFSIU) - I$$UANCEIDATE
which emit hazardous air coatandrants as defined by the gay Area Air
-•
Quality Management District? BOILER-COMP PFI'OR 100,IXq BTU) e
M Yes
have read the haves ow nutedalercquImmenh under Cha peer 6.95 of BOILER-COMP(OVER 100,000 BN)
the California Health h Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEWRFSIDEN'ITALMECH. SQ.FI'. , : r ni{r :d n•t +T3inry
rnponsibilitytonoiifythe.pantoftherequiamentswhichmustbemet
phorlolssuanceofa Certificateof Occupancy.
Ownerorauthodad agent - Date TOTAL: ISSUEDBY:"
'
OFFICE COPY .