19889 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Peale I Identification ,a_r.--T PERMIT NO.
Building Address:
VY/II19889
vllfeu i t,
nor. ame: I'lons:
APPI1nVff5R3T7ff7nTA p
CITY OF CUPERTINO-BUILDING DIVISION /��Q
Chntre NN+ame: LIc.Nm APPLICATION / PERMIT
373606 BUILDING-ELECTRICAL PMUMBI NG-M ECHAMCAL CATEGORY CONTROL#
.'
Archk /FgJacer. LIC No,
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address ���� ✓, m PERMHIS5UANCE ❑ ❑ ❑
LICI.NSF.D CONTRACTOR'S DECLARATION
I hereby affirm that l am llcensed under provisions of Chapter9(cummsu, APPUANCES-RESIDENTIAL JOB DESCILIMON
Ingwith Sd1dm7000)m Divlslan3ofthe Businessand Profession.Cpde,and my s
license is in full��f�of�� d&in . //s1����'' �y-Y1'_/ PANELS
License Class 366 ;;W Contact.,
lwTO� 3/-fi e ��� l I
Date 3//��ll CHITECr n7geDECLARATION
/ C/f
RCHITECPSDECLARATION 201-1000 AMPS
00 Z I u dp erg m p ru hallbe used as public remrda. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/
q� C a
)4 d(0 LIa tiro SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
I hereb affirm that lam exemptfromthe Contractors License law(m the
F Z F following reason.(Seaton 7031.5, usiness and ProonsfessiCade:Any cttyor gyp. ORPOL ST.
rountywhlch requires a perrnit to wmtmd,alter,lmpmvg demolish,or espair
41 .� any structure prim to its issue nee,also requires the applicant for suchpermlt to IOWERD
reU file a signed statement that he ls licensed pursuant to the provisions of the
Contractor's Licerese Law(Chapt9(convemo n 1th Section 7000)of Divl-
3OC slon3 ofthe Bustnessand PrefemionsCede)orthatt he is exempt thercfromand SWIMMING L C1RIC VALU B
S`ur1 6 5 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSWITC FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars hepr. NEW RFSID ELECTR I SQ. STORIES IYPECONSTRUCTION
❑1,as owner of the property,or my employed with wages r there sok
�/< compensation,will dothe estand kdessimand s Code:Th not intended orofferedLaw
9 p sale snot 7064,to an ow and f property
Code:The or improves
License law
did not apply to work
owner of progeny who Wilds mi or imp rov thereon,and OC GR Ice RFS.UMTS
whododsuchwork himseBmthraagh Msownempioyees,Arovided that such
improvements am not intended oroffered forsale.If,however thebuilding or TOTAL:
improvement is sold within oneyearofcompletlon,the owner-bulkarwlll have
th,j7a,den of proving that he did not bund.,improve for purpose ofinle.). QTY. PLUMBING PERMIT FEE vWoDjAqrjE APN
I_I 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contraama to romtrua the project(Set 7044,Business and Prefdalms Code: ,OD
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves,thveon, and who contracts for such plojects with a
, .ctor(s)licensed p....at to the Cmususar'a License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Il,l�fT
L j I am exempt under Sec B &P C for this reason
OUTSI DE FEES
�l DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT#
WOR KM AN COMPENSATIONDECLARATION .NgEs PER Lgpi. U/t SCHOOL TAX Y_ N_
01 hereby affirm that I have a certificate of consent to self-Insure,ora V RECEIPT#
certifIM IMC.)
Compensallonlmurancemacertlfkd ropythemo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Moo,labCJ RECEIPT M
Policy p GAS EA.SYSTEM-OVER 4(FA)
Cam any BUILDING DIVISION FRES
Certified copy a hereby fumlshed. GREASE/INDUSTRL WASTE INI'FRCEPTOR PLANCHECK FEE
❑Certifted ropy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID_C
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.MFT. Date Recei t#
Uhissealon need not he completed lithe permit b for one hundred dollars
(S1 W)or less) WATER HEATER W/VENT/F7.FCTR ENERGY FEE Y_ N_
1 comlythat in the performance ofthe work forwhlch this permit is issued,
I shall not employ any person in any manner so as to become subject to the ' WAIPR gySTFM/iRFATING D PAID �—
Workcrs Compensation taws of California.Date
O Applicant NEW RES DEM AL PCMB. SQ.FT. Date ReceI t#
Z Z NOTICETO MPLICArJT.1f,aher.a .gthls Cedift.teof Fxemp[lon,you
0 should become subject to the Workers''Comperuatlon provisions of the Labor TOTAL:
N Code,you most forthwith comply with such pravLdom orthls permit shall be BUILDING FEE
2 j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE _
�- Iherebyaffiran that there is a mmtrualon lendingagency for the perform- ELECTRIC FEE
M Z ante of the work for which this permit Is Issued(Sec.309'/,Civ.Q TOTAL:
U O Leader'.some W PLUMBING FEE
IL F- leaders Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I redifythat l have read thlsappliationand statethat theabove information
O W iscorea.Iagree to complywith all cityand county ordinances and state laws PFRMIT ISSUANCE FEES PAID
>. C relating to building construction,and hereby authorize representatives ofthi,
H N city to enter upon the aboveo-mentloned property for Inspection purpose.. ALTER OR ADD TO MSCH. O[I
Z (We)agree to"Vol Ind Pty an d krep harmless the City of Cupertino Date Reecipt#
V agabat,bill, sand expenses which may In anywayamrae AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL: _
agalnsbald eta sen of the gra rating of Id pertni
�+O AIRHANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX
si rcu putant/c.mraetor Dae IXFLAus'r Hoop(w/Doers CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Receipt# 116-011
renal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hal and Safety Code Seaton 25537W)7 HEATING UNIT(OVERIW,000 BTU) TOTAL:
7�Y�1 Yca
MN.
iIi the applicant orfrture building occupant use equipment or devices VEN"UTATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamrdous air contaminants as defined by the Bay Area Air a—,�
Qu ty Management District? BOILER-COMPpFB'OR 1110,000 BTU) sraa-yao6a1P3 ql]'p�
jYQ Y e No --r"" J! a4
Bread the haze uus materials requlrcmenb under Chapter 6.95 of BOILER-COMP(OVER 100,000BN)
the California l iealth&Safety Code,Sections 25505,25533 and 25534. I �6^1
understantl that) els does not currently have a tenant,that It is my NENRESIDENTIALMECH. SQ.FI'. b`
rcspoddi Iny a panto(the requirement.which must be met
P r rmlssu nific sofOccvpanry. -(��'
crorau oriadagent Date ISSUED BY: /^-
IOTAL: -
OFFICE COPY