19784 (2) APPLICANT TO FILL IN INFORMATION.WITHIN RED LINES - USE BALL POINT PEN ONLY
Building 1'rmrect Identification - - PERMIT NO.
Building Address: — - 19784
� /'1 n A
ossa ame: Phone: _ I �M/ w{ 4
(�' • '"P'0.D- CITY OF CUPERTINO-BUILDING DIVISION
• •NaNn: APPLICATION / PERMITIFAJ ad in 5, �J
BUILDING-ELECnUCALPLUMBING-MECIf NICAL CATEGORY CONTROL 0
Architect/"gears Llc.No:
` - ,QitYp;, '.i1 ELECTRICPERMIT t( Ott ;'- PEE 4�C' 00BUILDING PERMIT INFO.. p:
Address �, •4'� S"� W`T �� ` •. pp2hgT155UANCE '
LICENSED CONTRACTOR'S DECLARATION" `
I hereby affirm that l am licensed under provisions ofChapter9(rommme. APPOANCFS ENTUL - JOB DLSCRIPTION
ingwlthSect1on7000)of Divialon3 o(the Businessand ProfesalonsCode,and my -
license
laln f d(ect. PANELS n• `pas (��+
Lica Was Lk.x _ V/W�\V`•tiC' "
Date Contractor — TI(1C.>• -
AmsH U CI.SDECLARA N 201-1000 I
a ov 1 Fr.IT.ODR AREA
q�vOO - Iunderetand my plansshagW used as publlcrerords. SQ. $/SQ.Ff. ,
d'U Licensed Professloml ', SIG USAWAL ;
<�< OWNER-BUILDER DECLARATION SPECIAL CUIT/M75C
71., E I hereby affirm that lam exempt from the Contactors Llmnse law for the -
pp following rent...(Section 7031.5,Business and Professions Code:An cit or
F-L y p TEMP.ME QR E
� countywhkh requlrnapermlttoronsWct,alter,lmprove,demolish,orrepair `
ggg anystmdumprlortolbissuancgabomquirestheappllcanttorsuch permitm PDADEVICES
file a signed statement that he b licensed pursuant to the provisions of the
3 n, Contractor's License law(Chapter 9(commencing with Section 7000)of Divi-
�OS don3 ofthe Business and Pro/esakns Code)orthat he b exempttherefromand SWP1 C C VALUATION
O the bods for the alleged exemption. Any violation of Section 7[81.5 by any OUTLE E H FS
applicant ore for a permit subjects the applicant to a civil penalty of not mthan
five hundred dollars(5500). NEW RES1D AL EL TR SQ.FT.
k Z 6 ❑I,as owner of the property,or my employees with wages as their side STORIES TYPE CONSTRUCTION
compenmtlon,wllldothe work and thestructum b not intended or offered for
p sale(Snc 7016,B ohne a and Professions Code:The Contractors Llceme Law
5� does not apply to an owner of property who Wilds or improves thereon,and
EE who does such work hirrvaelforthrough his own employees,provided that such OCC.GROUP. RIS.ONUS
Improvements arc not intended oroffered foreale.IL however the W ilding or TOTAL:
Improvement issold withlnoneyearofcompietion,the owner-bullderwill have $
tl),k rden of proving that he did not Wild or improve for purpose of sale.). QTy. MI �
tat .a PWM9IN6'PERT"""' �iIi FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively mntratting with Ikenxd Pp(MR LSSUANCE
contractom to construct the project(Sec.7014,Business and Professions Cade: r,
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improvesn,thereoand who contracts for such to,jects with a '��, •
c tt(aetorid Demand pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE i' ",FEE'$UMMARY
L,J 1 am exempt under Sec g &'P C for this rcawn
QUTRI QE FEE S
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEPT N
WORKMAN COMP ENSATION DECLARATION FIXTURES PER TRAP - SCHOOL TAX Y_ N
01 seamy affirm that I have a certificate of caneem to opythsure,ora - RECEIVE M
38M.rtiab of Work/e�ra'Com� p(ensatlmnlmurnnce oracertl(Ied ropythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKF6 Y N
Pollry a W.11-I I V�� - GAS.EA.SYSTEM-OVER A(FA) RLCI]PT p
Com a y {-{ J _ ,. -� �z__�- -�_� BUILDING DIVISION FEES
ertificd copy b herebyfurnished.the city
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCI'JECIC FEE
Cert[/led mpy b(lied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR REDS' ` GREASETRAP TlsPAID `
COMPENSATION INSURANCE SEWER SANITARY
(Isection road not becomplamd lfthe peas[tato...hundred dollars - STORM EA.2WFT. Date Reed t#
($IW)orless.) WATER:HEATERw/vENT/ax i ' ENERGY FEE Y N
I mrtRy that in the performance ofthe work forwhich this permit liliasd;`
I shall not employ any person In any manner m v to become subject to the WATEIR SYSTEM/TREATING - ,
Workcra'CompensaHonLas"ve of Glifornla.Dam PAID . . .
Z Z, NOTICE / NEW RESIDENTIAL I'LMB._SQFE. - Date Recei t#
Z O NOTICE TO AI'PLICANT:ILafter nuking fhb Certificate of Exemptkn,you
Fshould become subject to the Worken'Compeluation provisions of the Labor J ., TOTAL:
N Code,you must forthwith inmply with such provisions or this permit hall W 'EU G
Wj dmmed revoked.- - FEE
G , CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hereby affirm that there iaacomtroction lending agency for the perforrry ELECTRIC FEE';
O ance ofthe work for whichthb permit is Issued(Sec.3097,Clv.C3 : TOTAL:
lenders Name '•' r , PLUMBING FEE,
LL I- lendre,Addres, QTY, it1' � MECHANICAL`I'ERMIT' ; ''FEE y MECHANICAL FEE
OwIcertify thatl have read this appllationand nate that the above Information
IL Is cormct.l agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
} M relating t o building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned erty propfor Impaction Ito u Tanana. ALTOR ADD TO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
O against liabilities,judgments,oarsman-expenses which may In any wayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag.o st,.1d City In ronxquence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000CFND CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will thoappDamorfuture building om pant store.,handle hazardous HEATING UNTEHO 100,000 Dili) -
material asdefined bythe Cupertino Municipal Cods,Chapter 9.12,and the _ _ Date Recei t#
Ilnalth and Safety Code Secelon 25532(x)7 HEATING UNIT(OVER 100,000 BI LD T -
-0 Yes M No -
Will the applicant orfuture building occupantuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANG
IMW
which emit havrdous air rontamlnanb as dented bythe Bay Area Air - � �
Qality Maaugoment District? BOILER-OOMPOFR'OR I0Q000 BTU) _
4 Yrs ,g No , TRJ Fb 17
havereadthe iealth a &YC-dr,Sealquiremenisunder Chapter6.95 of BOILER-COMP(OVER 100,OOD BTU)
theerstann t H i tthe Safety Cods SoiUons255Q5,ve a tend,that it "���as
understand that itthethe occingupant
pantdoes not the
menta which that it bay NEW NESIDEMIAL MECH. S'Q.IrI'. - •k�(J L7dl��Q2�/0/Taa�e/s
responsibilityne notify the occupant of the requirements which must W met r
6prigua,nce ofaCertlficate f airy �ehoriud agent _ -a�
TOTAL: ISSUED 6Y:\
OFFICE COPY