19757 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Bulld1ng Addreu:X1 atr4al, T) 19757
J%41TE
*� Phone
I"lr�� Ile-(\ a-S 40x-4 CITY OF CUPERTINO-BUILDINGDIVISION A A
Contraaor'aN uc.Nr: APPLICATION I PERMIT
- 4& BUILDING-ELF MCALPLUMBINC-MECHAMCAL CATEGORY CONTROL M
Archlt /Englnxr. Lie,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ El 1:1LICENSED CONTRACTOR'S DECLARATION
Iherebyafflrtn that l am licensed under provisions of Chapter 9(commene APPLIANCESRESLDENMI, JOB DESCRIPTION
Ingwith SccBon7000)of Dlvklon3 ofthe Businessand Prefesslon.Ccode,and my
Itcense Is,in full force and affect. PANELS
Llcenx CkmN
r Llc.
Date —Contractor or _ UP TO 200 ANTSARCHITECT'S DECLARATION 201'1000 AMPS
otO Zp I understand my plans shall be used es public records. OVER1000AMPS SQ.FF.FLOOR AREA E/SQ.FT.
Z Licnnxd Professlonul SIGNS ELECTRICAL
<f OWNER-BUILDER DECLARATION SPECIAL CIRCUIT LSC
Z t, � I hereby affirm that l am exempt from the Contractor'.License law for the
po courtingreason.requires
rmit5,Bratne9 and Improve,
Code:Mycity it
TEMP.METER E INSI.
Fy
any
reior to tna latmittocoalso resta,alter,rres the applicant
fors &prmit to
M_ < any assigned statement
Chaconne Restated pursuant to the prrauchpeof to MWERDEVI
O c.0 floe a signed statement that he is Bcenxd pursuant it the tion 70om of the
Xw Contntorb License law(Chapter9(commencing with Section 7000)of Divi. SWAIMING POOL E
05 a1on3ofthe Bus,lnnsand Prof.n ru Code)orthathehe¢mpttherefromand VALUATION
yl the basis for the alleged exemption. My violation of Section 7031.5 by any
applicant fora Parrett subjects,the applicant to a civil penalty a not more than OUTLETSSWITC
dred
five F11,a...at of the prey NEW RESIDENTIAL EL" SQFF.
I,as owner of the property,or my employees with wage as,their sok STORIES TYPE CONSTRUCTION
<
compares alion,will Bothe work and lhestracture is not intended or offered for
p sok(Sec.7044,Business and Profe lom Code:The Contnaoes License Law
$ does not a pply to an owner of property who builds or improves thereon,and .
c- who does such work hiesselforthmagh his own employ.,provided that such OCC.GROUP RISUNITS
Improvements are not Intended oroffered forsale.11,however,thebullalegor TOTAL: (�
impemerrnnt'.sold wlthlnoneyearofcompletion,lheowner-bullderwill have ELS
t Iden of proving that he did ns,build or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZANE AI'N
\ XI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mmtmd the project(See.7W4,Business and Professions Code:
:\ The Contractor's License Law does ns,apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
WOds or Improves,thereon, and who contracts for such pea)ects with a
o'I ctor(s)1 enxd pursuant to the Contractor'sLlcenx Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
c LJI
Is. x t o Sec. B&P C for this reason
Owner �.�( z3h�Tv— DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Date�-O tom/V RECEIPT It
ORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certNcate of consent to pyths,ure ora HXNRFS PER TRAP SCITOOL TAX Y N
certicinte of Workers'Competuatlan Imunnceora certlfkd copythema 6ec. RECEIPT M
38001lois CJ GAS EA.SYSFFM-1 INCA OUTLETS PARK EI>: Y N
Paley M
CffCany
GAS EA.SYSTIM-0VER4(EA) RECEIPF M
iRed copybereby famished. BUILDING DIV
ISION FEES
[:]CrAlRed copy b(kd with the city
lupe<ion division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK PEE
CERTIFICATEOFEXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(I'hlaxctionnced net becompleted Bthe,permi[isforon,hundred dollars SEWER-SANITARY-STORM M.200FF. Date Recei t#
(EI I()orfWATER ENERGY FEE Y N
Icertl(y that in the performance of the work forwhkhthb permit Is lswHEATER W/VENT/ELECTR cd, N—
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
O Z Applicant
Z O NOTICEIOAPPLICANT:ILakermakingthk Certlfkateof Exemption,you NEN'RESIDENTIAL PLMB. SQFT. Dale Recei t#
N
should become subject to the Workers Comperssacfon provisions of the Labor TOTAL:
Code,you must forthwith comply with such pisioor this permit shall be
LU > rovns deemed re°nked' BUILDING FEE aGb
CL 0 CONSTRUCTION LENDING AGENCY SEISMIC FEE a
I hereby a M rm that there is a construction lend ing agency for the perform TOTAL: ELECTRIC FEE
M Z sone of work for which this permit k issed(Sec-309'/,Civ,CJ
LL Q lenders Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrtlfythallhavercad this appBcetionand satethat lheabovelnformation
1 u correct l agree to comply with all city and county ordinances and state laws, PERMRISSUANCE FEE$PAI-D-
>.
N relating to building constructor,and hereby authorize representatives ofthis
Z city to enter upon the above,mentioned property for Inspection put rposes. ALTER OR AUDIO MECH.
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino DECONRUC7TIONAX,
tReceipt#
against liabilities,judgments,copsand expenses which may In anywayaccrue AIR HANDLING UNIT CFO 10,000 CFM) :
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER IQ"CEM)
Slgrutureof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) ID:
HAZARDOUS MATERIALS DISCLOSUREWill thcapplicanl or future building occupant store or handle hazardous HEATINGUMT(TO 100,=BTU)
rramrtatasdefined by the Cupertino Municipal Code,Chapter 9.12,and the Healthand SafelyCode Sectlon25532(a)7 HrATING UNLT(OVER 100,(00 BTU) : J"Ixt-J
n�'I Yes No
TVllltheappllnnt oruture building ocmpantuse equipment or devices VEN1LATION FAN(SINGLE RESID) ISSUANCE DATE
which runt hazardous air conga minants as cie(ired by the Bay Area Air
Quality Management Distact7 BOILER-COMP OHP OR 100.IX1D BTU)
4Yea ❑No piI®�%l1
havereadlhehuallousnuterialsrequfrementsunderChapter6.95of BOILER-COMP(OVER IW,000BTU) �aTOL9
the California Health&Safety Code,Sections 2550.5,25533 and 25534. I FED
understand that if the building does not currently have a tenant,that it k my NEWRESIDENDALMECH. SQFL FED G 1x tJ.0
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Onvpa racy.
of elf""Tsn.m _
Owner or aulhorlud agent pate •T�••�- r1�1\�Ulal
TOTAL: ISSUED BY: �J
OFFICE COPY