19953 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
tluildln I'm'mt Identification PERMIT NO.
Building Address: 19953
/0 YOO e/7) � � T
n Phone: A
Dm;. � CITY OF CUPERTINO-BUILDING DIVISION
cnntra,tnr.Name: ur.No/: APPLICATION /PERMIT
S l99 C7��Olo BUILDING-ELE MCALPLUMBING-MECHAMCAL CATEGORY CONTROL
Arehilect/Engirreer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam lcemud under provlslonsof Chapter9(comment APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwilh Section 7000)of Division ofthe Bustnnssand Pretend onsCodo,and my
license b In ha fr apd of ed' PANELS
Ll .Class C-dfv�:bLic.# 373 �D 6 (�
Date Contractor
ARCHITECPS DECLARATION 201-1000AMPS
7. I understand my pians sial be used ns public records OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
CO
Z(� Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION
fna FS SPECIALCIRC T/M
7 s'�j.-�a owing rasonn"hatln 7exempt!romthed Professions ode:ense law fort he
h following reason.(Section rmf1.5,Business and Professions Code:Any city it TEMP.MECEt 0 L INST.
E
coo ntywhlch r,qulrcsa perattoconstruct,alteq Improve,d,molbM1,or repair
GS�EE anystrucema pdorlo its issuance,abo requiresthe applicant fee such permit to POWEADEVIC*�
file a signed statement that he is licensed pursuant to the provisions of the
O Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. 5 ELE
0 simlofibe Bualnessand Prohadma Cod0ortha hehomm therefroand VALUATION
Q1- S thebasisfartheallegedexemptlon. Anyviolationof Section" m7m1.Sbyany OUTL, E
<� applicant fora permit subjects the applicant to a civil penalty of not more than
e. Ove hundred dollars($500). NEW DENTIAL TR SQFr. STORIES TYI'ECONSIRUCTION
C'< ❑1,as owner of the property,or my employees with wages as their sole
p,nsstlor,wOidotheworkandthest d=mlanMIntendedoroffered for
D sale(Sec.7044,Business and Professions Code:The Contractor's License law
({$$ docs not apply to an owner of property who Wilds or Improves themer,and OCC.GROIIP RIS.UNITS
E whodocssuchworkhiwciforlhmugh hisownemployces,provided thatsuch
Improvements am not Intended oroffered forsals.If,however,thebullding or TOTAL:
i provementissoldwithinoneyearofcompletion,theowner-Wliderwlllhave
thAucien of proving that he did not build or improve for purpose ofmle.). QTY, PLUMBING PERMIT FEE FLOOD IONS APN
L_j L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN kVENT-WATER BINWilds or Improves thereon,and who contracts for such projects with a FEE SUMMARY
contractoru)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B 6 P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONI). SANITARY Y_ N
• Owner Date RFAER'TN
WORKMAN COMPENSATION DECLARATION FILATURES.PER TRAP SCHOOL TAX Y N
❑[hereby affirm that I have a certificate of consent m self-insure,ora RECEIPT#
matflcateof Worke Comperoatlonlmuranceoracenifledcopythemcf(Sec. GAS F.A.SY57FMdINC.d OUTLETS PARK FEEY N-
00,lab CJ
Policy# RECO D #
I
GAS 7M
EA.SY57 -OVER 4(EA) BUILDING DIVISION FEES
IMACenlfled copy is hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certlfled copy is filed with the city Inspection division.
CERTIFICATE OF EXOM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SAMTARY-STORM EA.200FT. Date RCmI t#
(This section need not he completed If the permit In for one hundred dollars
(1100nrland.) WATER HeATERw/vENT/E-ECTft ENERGY FEE Y_ N_
1 cartlfy that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING
Workcrs'Compensation Lawn o(Callfornla.Data PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQ.FI'.
PDate Remi t#
Z O NOTICE TO APPLICANT.U,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthu permit shall be BUILDING FE'
cc U)
deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC PEE
a Iherebyaffirmthat there la a construction lending agency for the perform- TOTAL: ELECTRIC FEE
7 Z are,oftbe work mrwhichthls permit la lassoed(See 309'7,Cw.C.)
O 1<nder'a NamPLUMBING FEE
(� e FEE L
LL I- L,nder's Address QTY. MECHANICAL PERMIT MECHANICAL FEE JL
0 U Imrtlfythatlhavemadthbapplcatlonandeatethattheaboveinfont tion FEES PAID:
W Is comet.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE 2`W
1 relating to building construction,and hereby authorlu epreentalwas of th is
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. �1 DaIC Receipt#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT(TO 10,000 CFM)
aga Wt IubIW In,pdgmen"s,roaUand expenxa which may In anywayaccrue SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appllcurt/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willlheappllcant or future budding occupant store or handle hazardous f TF-ATTNC UMT(T0100,0001311T) Date RCCeI t#
materul as defined by the Cupertino Municipal Code,Chapter 9.11,and the
I lealth and Safety Cad,Section 25532(a)7 HEATING UNIT(OVER lad"BTU) TOTAL:
❑ Yea nNo
Will the applicant or fumy building occupant use equlpment ordevices VENTILATION FAN(SINGLE RESID) �0 PAW ANCE DATE
which eat hazardmaslr emundranlsas defined by the Bay Area Air �- f'
Quality Management DistriR7 BOILER-COMP DFP OR 100,"BTU) OTTu
4yen ❑❑No
haveread the hazardousmaterials requircmentsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) 4 •Lv( U 3
the California I lealth h Safety Code,Sections 75505,15533 and 25534.I y.
understand that lithe notify the occupant
not the
h.mves which,that b met NEW RESIDENTIAL MECH. �.FL
responsibility to notify th,«apart of the requircrrcnts which must be met
prio�r" uance of rtificalc ofOaupanry.
3—L3�17 .f�''�
OvOner or authoriced agent Data TOTAL: Q ISSUED BY:�IuLi lYl Vuty—GL
a
OFFICE COPY