21574 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification ,� _ PERMITNO.
1,
Building Address: -/ O.
os/�� 5746 umi'/li2D �/'c .
n e,
A
6,
w era amc: �S °�, CITY OF CUPERTINO-BUILDING DIVISION
Cent cwe suc.Nn: ' APPLICATION / PERMIT
/
-�� a G BULDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
Architect/Engineer: - LI[.No:
r " "BUILDING PERMIT-
INFO,:,
- _ Qi'Y _. EL6CTRIC'PERINIT ..F'EE"�
AddressPLUMB
- PERMITISSUANCE -- ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMhSadioi 7000)o Divsim3 ftheBuir sandPm Chapter9( and c- API'LIANCFSRESIDENTIAC JOB DFSCRE'110N
ingn"' Section 7000)of Dlvlslon3o(rhe Bueinesaand Pro(esalonaCode,and my
license Is in fu�for ad effect PANES
License ClaelM1%� LION - 7 � �lk-e
is sea+ Contractor ".Q' Mrd)fA UP TO 200 AMPS
ARCHITECr DECLA 101-1000AMPS
N O I understand my plans shall be used as public rerords.. OVER]000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Poi Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDERIDECLARATION SPECLILCIRCUT/MISC
7H � Iherebyaffirmthat lem exempt from the Contractor'a License law for the
o following reason.(Section 70313,Business and Professions Code:Any city or
L t. TEMP.METER OR POLE INST.
following
reason.
(Section
7Mt to Bust ass an ey improons Cod 0sh,or ity or
g anystmctam prlorto its buseance,alsorequiresthe applicant for uch perMtto POWER DEVICES
`S file a signed statement that he Is licensed pursuant to the provisions of the
3�•, t
Contracor's License Law(Chapter 9(rommentlngwlthSect1on70M)ofDivl-
SWIMMING IX30L ELECTRIC
slon3oflheBusinesa and Profexlonn Code)orthat he Vexempttherefromand - VALUATION'
G net morethan the basis for the alleged exemption. Any violation of Section 7031.5 by any v
applicant for a permitsubjectsthe applicamte a civil penalty of OUTLETSSWITCHESEXTURFS /C
/J
five hundred delta.($500). NEW RESIDENTIAL ELECTR
�n
F-1 1,as owner of the property,or my employees with wages as their sale SQ FT. STORIERTYPE CONSTRUCTION
compensation,will do the work and the structure isnot intended or offered for /
O sale(Sec.7044,Business end Professions Code:The Contractors License Law
$ does not apply to an owner of property who bulldsor improves thereon,and OCC.GRO[JI' RES.UMTS
who doessucWcal,himself uthrough hi.mve employees,provided that such
improvements are not intended oroffered forsals.If,however,thebullding or TOTAL:
i provemembsoldwithln omyearofcomplellon,theowner-builderwlli have -
t .burden of pioving that he did net build or improve for purpose of sale.). Q7y; :1''. gPLUIVl$ING'PERMIT .'P E'`( PLOODZDNE APN
u L as owner of the property,am exclusively contratling wllh licensed PERMIT ISSUANCE
contractors to contract the project(Sec.7044,Business and Professbtu Code:
The Contmctor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for for such ppsjwith a • +FEE',$IIMMARY.
It{actor(s)licensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE
U[am exempt under&c B &P C reas
for this on
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N.
Date RECEIPT N
T WORKMAN COMPENSATIONDECIARATION FD(TURES PER TRAP SCHOOL TAX Y N
hereby affbm that I have a certificate of consent to selNesure,ora R— a
3&10Lab CJ
cert BceteofWorkers'Compensationlmumnama,mtife mpythemof(Sec. 'GAEA.SYSTEM-1 INC.40UTLE75 PARK FEE Y N c
, nnn
S
- Policy N `I p
79) RECEIPT
CAS EA.SYSTEM-OVER 4(RA)
Com any_ r. BUILDING DIVISION Fr.ES
Certified copy is herebyMouthed.the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
�G'etllfied copy Is(fled with the city inspection division. .. ,.
1 CERTIFICATE OFEXEMITION FROM WORKERS' GREASETRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARY-BTORM EA.200FT. Date Recei t#
(Thm I..on need net be completed tithe permit la(or one hundred dollare
(81 Ic)arlessJ WATER HEATER W/VENT/E-ECTR ENERGY FEE Y N—
I
ll notcerlify that emin ploy
anyhe arson I an the near
for to be. subjrmitect
c issued,the —
I shall not employ any person In any manner ro u to becorce subject to the WATER SYSTEM/TREATING
Applicant
lican Compensation Laws o(GII(omla.Date PAID
Q Z NOTICE
NEWREEDENTIALPLMB. SQTf. Date Remi t#
Z O NOTICEco APPLICANT:If,after
orkem' ompeng asationlotc of Exemption,you s
should become subject to the Workers'Compensation provisioru of the Labor TOTAL:
N Code,you moat forthwith comply with such provlshuamthbperretahallbe S:Dd
y destruct revoked.
BUILDING FEE
LU
mG . CONSTRUCTION LENDING AGENCY SEISMIC
I hereby affirm that there Is a construction lending agency for the perform EE
SEISMIC FFEE
Z anceoftheworkfor whichthls permit is Issued(Sec.3097,CIv.CJ TOTAL
V O Lenders Name PLUMBING FEE'
IL F Leadce.Addresa MECHANICAL FEE
OW Iamilylhatl havereadthisapplicalion and starethattheaboveinformatlon
4 Is correct.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to bullding comruction,and herebyauthorize representatives alibis
H Z city to enter upon the abovamentioned property for inspection purposes. ALTERORADDTOMWH.
_ )agree to nave,Indemnify an d keep Mean the Clty of Cupertino Dale Receipt# .
a ria IlabNtlee,pdgmenb,mste ed expo hlcbeen In any v.yacaue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL;
a a said tyro ron uen�gpJgthe gran of this permit
.�4Z, 9 AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTIONTAX
SI ature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date R00e1 [#
material as defined by the Cupertino Municipal Code,Chapter 9.1$'and the
Ifraithand SafetyCodoa 75532(x)7 HEATING UNIT(OVER 100,000 BTU ' TOTAL:
M Yes .,
Will the applies orfuture ding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemit hazardous air con nano as defined bythe Bay Area Air
Quality Management 'sir BOILER-COMP QHPOR 100,000 BTU - PAW
II�7 Yes No
havemadtheh us matedalsrequirementsunder Chapter6.95of BOILHR-COMP(OVER 100,000 BTU) �� �^ (]A}
the California Healt &Safety Cade,Sedions25505,2S533and2$34.1 (,a �.7x7f
understand that if the building doer not currently hav tenant,that it is my �. NEW RESIDENTIAL MECH. SQ.FT.
responi) tytonot then antofth quire wIt hmust be met _
r Prior td anreo( Certific giros _
Own or authorized agent 7 Date `
.. TOTAIi ISSUED BY:
OFFICE COPY