19759 (2) "ICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
Building Project Identification PEIIMIT NO.
aBding Addreaa: - - - 1.9759
where me. _ phone: -
CITY OF CUPERTINO-BUILDING DIVISION -.
contra°°''.Name: Lie.No: APPLICATION /PERMIT
-BUILDINCELECTRICALPLUMBLNG-MECHANICAL CATEGORY, CONTROL.
Architect/Engineer. Lk.No:
ELECTRIC PERMIT 1 a" t,"FEEt t: l• '4t BUICDINGjPERMIT.INFO ,
Address: ppAgTISSUANCE �• �j '
LICItNSBDCONTR under 'DECLARATION
Ihereby dionaffirm that lam licensed Buinessand Pre Chapter9de,and c APPUANCFSRESIDENTIAL JOB DESCRIPTION
InenseISection to.
dean3o(the Buslnessand Pro(nslons Code,andm
license iCla full force and effect. - PANELS rt
Date Contncior 201-
ARCHITECT'S DECLARATION 1000 AMl5
qZ I understand my plans stall be used as public records. OVER 1000 AMPS I SQ.FF.FLOOR AREA.: $/SQ.FT.
Licensed Professional. 1, gIGNSELEC CAL
GGtLgo OWNER-BUILDER DECLARATION .- SPECIALC NT/
Iherebyaffi'mthatI am exempt from the Contractor's License law for the
OO sw Ix
following mason.(Section 7031.5,Business and Professions Code:Any city or
'OZi. TEMP.M LE INS '
r� cauntywhkh requires a permit m construct,alter,improve,demoBsh,ormpd,
anystmcturepdortolbbwance,a]s qulmstheapplicantforsuchp.r tto POWER C S -.
p U file a signed statement that he is licensed pursuant to the provislom of the Commences License Law(Chapter 9(mmmenctng with Section 7000)of Divi- -
• SOS sionI of he Business and ProfessimaCode)or that he is exempt therefrom and 7NEWMID
POOL EL RIC' VALUATIONthe basis for the alleged exemption. Any violation of Section 7031.5 by any _0X ppBantfora permltsubjedatheappOcant too tlWl pe,altyfnot rtnrelhan SBW) • Fl1�hyndred hvhtloidlnh roEQ.FT. STOIUFS TYPECONSTRUCTION
�, I�7asowner It the property,or my employcc.with wages r thele sole AL EL
Z coTipensatlon,wllldothe workandthestrocturebna Ntended or offend for
- -
pIe(Sec.7044,Business and Profesimu Code:The Contractors License law
dace not apply to an owner of property who Wilds or improves lhcmoq and. OCC.GROUP RFS.UNITS
C: whodon such work himself or through his own employees,provided that such
improvementa are not intended oroffered forsale.ILhowever,the Wildingor TOTAL:
Improvement issold within oneyearo(completion,the owner-bullderwili have
lnc*rden of proving that he did not Wild or improve(or purpose ofulc.). Qjy, IPLUMBING'PERMITI, �I`(I ^)J•EE"'� FLOOD 7p ArN
LI I,as owner of the property,am exclusively contraning with Ikenxd PERMIT ISSUANCE
contractors to mostrud the project(Sec.7064,Business and professions Code: � -
The Contractors License law don not apply to an owner of property who ALTER-DRAiNk VENT-
. Wilda or improve hereon,and who cmuraRa
.the COntractor'e License Lawfor such-pkajects with a WATER(EA)
actor(s)Ike ursuat . ..ej•#r",�t`I')'",.°FEESUMMARY,
ed
B k P C for this mown BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
LJ I am ev t n r e
Owner a ate, ,_ DRAINS FLOOR,ROOF,AREA,COND.* SANITARY- Y_ N_ '
RPA
EIF% EIFp
R t 1P:NBA ION FD11 LARATI N
❑ hereby affirm that I have a certificate InwMTIRPES PER TRAP SCI{OOL TAX Y— N
cate of conto eel(-
re,or RECEIPT M .
certificate ofWorkera Compensatlonlosurance or a certified ropy thereof(Sec. GAS EA.SYS'1'Qd-1 BJC40UTLBTS a
3800,lab C.) PARK FEE Y_ N_
policy N RECEETp
CGA.SYSTEM-OVER
SION PIKSffCertY BUILDINGDIVI
Bled
ropy Is hereby te city
Certified mpybfiled withh the dty Inspection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE '
❑ ty "
CERT LOCATE OF EREMITION FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORm FA 200FI Date RCC21 I#
(Thlssection need not becompleted tithe permit bforomhundred dollars
IS=or WATER HEATER W/VExl'/ELECTR ENERGY FEE Y N '
Icertify that In the performance ofthe work forwhich this permit is bored, —
I shall not employ any person In any manner an as to become subject to the WA7TR SYSTLhf/TAEA77NG _ It
Workcr%Compensation Laws of California.Date ".
O _ PAID
Z NOTICETO APPLICANT:If,after mokingthb Certificate of Examption,you NEW RESIDENTIAL PLMB. SQ.FF. Date. RCCY'1 1#
Z Applimnt
should becomesubjeetto the Workers'Compensation provisions ofthe Labor -. TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be
> cieemedrevoked. � .-. UI G •'E c
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE 6
M IhercbyafBrmthatthereb a cemomctlon lendinghgency forthe perform- TOTAL:, ELECTRIC FEE Q
Z anceofthe workforwhichthls permit b issued(Sec.3097,CIv.C.)
o2 L.ender.N.me - - PLUMBING FEE
IL Lenders Addreas O Y. MECHANICAL PERMIT'S FEE; MECHANICAL FEE
OW Icertifythat l have read thisappllcatlonend stanthattheabove,Information -
C is correct.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building camtmctlon,and Mrcby authodae representatives of this
-
-(— Z city to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH.
V — (We)agree to save,Indemnify an If keep harmless the City of Cupertino - Date Receipt#
against liabilities,Ndgesmas,eentsand expense.which may In any way accrue Al R HANDUNC UNIT(TO 10,000 CFM) SUBTOTAL:
aga lost said City In consequence of the grant ing of this permit.
AIR HANDLING UNIT(OVER 10,000 CEM) CONSTRUCTION TAX- -
Signature of Applicant/Contractor Data EXHAus"r HooD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wiilthe applicant or future bulldingoccupant pore or handle harardous HEATING UMT(TO 100,000 BM
material as defined bythe Cupertino Municipal Code,Chapter9.1Z and the Dale Reeei f#
Health and Safety Code Section 2M32(a)? "' _ HEATING UNIT(OVER 100,000 BTUs TAL: .�
1-1Yes rr��J NO _
Will theappllwntorfuture building occupant use equipment ordevicn VENTILATION PAN(SINGLE RESID) •(S$ (DATE
which emit harardous air contaminants as defined by the Bay Arca AIr
Quality Management District? BOILFR-COMPOIIPOR100,000BTIA
Yes � a - - t •<.
haveread thehara et Code, salon 25SO5, under Chapter&95 of BOILER-COMP(OVQt lOD,000 BTU)
the California Heall Safety Code,Sections 25505,25533and 25534.1 -
understand that it a ulldingdoe imrrently havealenanq that itbmy NEW RESIDENTIAL MECH. SQ.FF. ?y Iux,�•�II,rrRly(nD
'!polis' Ito to' the. n ftherequire ntswhichmustbemet — •�/—'
prtorto ua of Ce IOc ccupancy..
Owneror unor and agent ' Date - ISSUED BY-.. ..11Tfslsa�w"-'ems (
TOTAL:
OFFICE COPY