24159 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification PIJ TNO
Bullding Address:
,z �.sn arts-v�us CaK BLVD Cufe¢V;V0 2.4159
hone: A=.
.._; ; �,.D'► ��.r1LN oQ'."52-5�Q�.Y! CITY OF CUPERTINO-BUILDING DIVISION
Contranor'sN - LIc.No: APPLICATION / PERMIT
S'•- - BUILDINGELECTRICAI:PLUMBINGMECHAMCAL CATGGOAY CONTROL p
.� Archltett/En sneer. LIC No:
° -t'. rr ,',BUILDING PERMIT INFO
,QTY" ) ELECTRIC�PERMITitt' FCE�°_
Address PERMITISSUANCE - ^0� - ,�. ❑ �.
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under rwBlons of Cha o mmenc APPLIANCES-RESIDENTIAL. . y P pterg( JOB DPSCRI'HON
licomeh l.full7000)of Dlvfeet. (1he8uslnessandProf.slonsCode,and my
limns,is In full(orcc and effett. PANELS
License Clam LICX - - (^•Q _ � GA
Date ont
.Cractor - - \ V�
ARCHITECTS DECLARATION .l 2014"AMPS P
CTn
�Z I understand my plans shall In,used as public records. 1000 AMPS FT.FLOOR' $/SQ.Fr'.
qqqqCO
' taC
�tj Licensed Professional -, SIGNSELECTRICAL {I it !� R
-�6 OWNER-BUILDER DECLARATION SPECALCIRCUIT/MISC `•
7p � IherebyafOrmthatlamemeeptfronethe Contractor's Licenselawforthe
O following reason.(Section 7031.5,Business and Professions Code:Any city orD
P2t.� countywhichrmpu aperndttocorutruct,alter,lmpmve,demailsh,ormpalr T P.METD20R POLE INST. TE
a aey.mucturs priorto Its Issuance,ahorequlreathe applicant forsuch permit to I'OWFR DEVICES
F file a signed settlement that he is licensed pursuant to the prewhdom of the -
3w Contractor's License law(Chapter 9 toonam Nng with Section 7000)of Divi-
SOS sionitofthe BushVALUATIONes...d1rofessionaCedOmthat helsexempttherefromand SWIMMING IDOL ELECTRIC .
y.' the basis for the alleged exemption. Any violation of Section 7031.5 by any Z]
p� applicant fora permit subjects the applicant to a civil penalty of not more titan OUIlETSSWITCI{FSFIXTURES 1
five radiad dollars(SSOO). SQ. STORIES TYPE CONSTRUCTION
as owner of the property,or my employees with wages as there dole
NEW RESIDENTIAL ELECTR Fr'.
mpensa M4,Busiothe ness
Ind rkand thes Code: heIs et Coo mun'ended or offeredLaw '
�O sale(Sec.7044 eueless and Professloro Code:The Contractale License Law
$ docs rad a pply to an net of property who builds or Improv.t hemon,and - "
F-$ OCC.GROUP RI'S.UNITSwhodoessuchworkhimselforth.ghhlsownemplayees,pmvidedthat.0 h
improvementsarenoH tendedorafferedfar,ale.IThowever,thebuildingor TOTAL: .Z� -
Improvementbsoldwithlnoneyearofcompletion,theowner-bullderwill have 4
tl6rden of proving that he did not build orlmprove for purpose ofsale.). QTY, PLUMBING PERMIT FEE' FLODD IONF APN.
u I,as net of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Professions Code:
'r The Contractors License law does not apply to an..or of property who . ALTER-DRAIN&VENT-WATER(FA)
Wilds or improves thereon, and who contracts for such ptpj cbs with a
cgp3factor(s) reaud pursuant to the Contranar's License Law. BACK FLOW PROTECT.DEVICE
I a empt un Sec. B&P C fo his maeonQUTSIDFFEFS
a�..• , 40
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N -
Owne Date RECEIPT X
' R PFNSATION DECLARATI N FI%.IVRFS PER TRAP - SC7{OOL TAX Y N
(hereby affirm that I have a certifies of carseat to rl(-Ineurc,or RECEIPT M
'mrtlflcate ofWorkers'Compensation Insurance can certified copy thereof CS". GAS EA.SYS77➢rfd INCA PARK FEE Y N
3XOQLab C.) - .
I'oilry p RIXGAS EA,SYSTEM-OVER 4.IRA) VING Of V
Com any - BUILDING DI VISION FEES
[Certified copy is hereby filed
the city
CREASE/INDUSTRL WASTE INTERCEPTOR PLAN CHECK FEE
'
Certified copybflied wish the city inspection division.
CERTIFICATE OF UEMPTION FROM WORKERS' GREASETRAP - - PAID
COMPENSATION INSURANCE SLWER-SAKITARY-STORM EA 2f0F1. Date RCCCI t#
QFieaettlonneed n.be
COMPENSATION
lithe permit bfor one hundred dollen
($100)orless3 WATER HEATER w/vENT/EI.LCTR ENERGY FEE Y N
'I crA fythat In the performance of the work forwhich this permit is issued, —
I shall not employ any person In any manner eo as to become subject to the WATER SYSTEM/TREATING
Workers'Compensailon laws of California. Date PAID
0 Z Applicant - - NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fshould bemmesubject to the Workers'Compensation prov6lom ofthe Labor TOTAL:
N Code,you must forthwith complywith such provisions orthb permltshall be BUILDING •E
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iberebyafflrm that there 6 a construction lending agency forthe perform- ELECTRIC FEE
7 Z ance of the workfor which this permit 6 issued(Sec.3097,Civ.C.) TOTAL: .2
V O Lender's Name - - - FEE PLUMBING FEE
IL F I.nder',Add. QTY. MECHIC
ANALtPERMIT °' MECHANICAL FEE
OW I certlfythatl have read thisappllcationand statethattheabove Information
S iscurret.I agreeto comply with all city and county ordlnancesand mate laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and herebyauthorizerepr.entativesofthb
FZ city to enter upon the abovo-rrentioned property for inspection purposes. ALTERORADDTOMLCH. Date RCCei i#
— Me)agree to save,indemnify an d keep harmless the City of Cu pert Inca P
agal Ila Mitt] gme ,.odaand expenses which may In anyway acme AIR HANDLING UNIT(TO 10,000CFM) 'SUBTOTAL:
ag ' tea n ence oLf tI/��granting of this L f/! AIR HANDLING UNIT(OVER 10,f00CFM) CONSTRUCTION TAX
Si nature of Applicant/Contractor Date EXHAU5THOOD(W/DUCT) CONSTRUCTION TAX PAID: -
HAL RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haurdous HEATING UNIT(TO IOLODO BTU) —Date RCCei [#
meredal as defined by the Cupertino Municipal Cod,Chapter 9.12,and the
Health arad Safety Code Section 25532(a)7 HEATING UNIT(OVER I00,0W BTU) TOTAL:
YesLs��1 No -
Wllltheappii.nt or fu tum building occupant use equipment ordevices VENTILATION FAN(SINGLE AFSID) ISSUANCE DATE
which emit ham rdous air contaminams as de fired by the Bay Arca Air
Qu Iity Management District?, 80ILER-COMP Of I'OR 100,000 BM Pr' pH ' D
4nYes n❑No P
havereadtheb.Qusmaterials requirements uoder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the Cailfomla HmIth&SafetyCode,Sectiom 25505,25533 and 75534. I AUG
understand that lithe building does not cumselly have a tenant,that It 6 my. NEW RESIDENTIAL MECH. SQ,FT 1992
'responsibility m re
notify the occupant of the requirements which must be t
prior to issuance of a Certificate of 0ccvpanry.
CI I Y tri v cn I uvv
Owner or authorized agent Date ISSUED BY:
TOTAL: —
OFFICE COPY