19907 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY "
Building Project Identification - PERMIT NO.
Building Address: 19907
Owner'sQX1 212=1
Name: Phone A A A
/'k, klL CITY OF CUPERTINO-BUILDING DIVISION c
Comm' Name: Lie.No: APPLICATION / PERMIT Z7 / v
"r BUILDINGELECTRICAI.I'LL7M8INGMECH LAICAL CATEGORY CONTROL X
Arch len Engineer Lk.Na:
QTY ELECTRIC PERMIT - ". FEE
BUILDING PERMIT INFO _
Address PERMITISWANCE f�.i' ❑ ❑ _
LICENSED ONTRd under S DECLARATION
I hereby withSction mthatl iv Bcensd underprevidonsef Chapter
Isions9(mmmmc APPLIANCES JOB DESCRIPTION
ingwlih Senion7000)ofD)vlsion3olshe Businessand larofessianaCAde,and my
license is In re deflect /_ PANELS
Lirenso hss k.X Y Q ( .1
Date Contactor ��...naa,�.� I M AI/Z
�pGH:d-; DECLA A 10 �XrsL� 201-1030 AMPS C0
ce 7 I understand my plam shall be used as public records. OVER IDDO AMTS SQ.FT.FLOOR AREA I 9/SQ.FT.
U0IJ Licensed SIGNSELECTk
7 OWNER-BUILDER DECLARATION SPECIAL CIRT/MISC
7L, u, Iherebyaffirmthat l am exempt from the Contractor's License Law for the -
G g h following reason.(5ection 7031.5,Business and Professions Code:Any city or TEMP.M OR N
SA
g countywhidtmqulresapermittommtmcl,altegU pmve,demolish,ormpalr
i< anystm=mpriurtoits Lssaance,abomprireslheappBantfomchpermitto )OWER DEVI
O file a signed statement that he b licensed pursuant to the provisions of the
Contractor's License FLaw(Chapter9(commencingwithSection7NO)ofDivi-
n SWIMMING IDOL ELECTRIC
O aon3of the Business and ProfesabroCode)orthat he is exem there(mmand VALUATION
^t ¢S the basis far the all eB d civilexemption. Any violation of Section 7MI5 by any OUTLETSSWITCHFSFlXTURES
.W7 appEcamfora pemtit subjcdsthe applicant to a civil pevltycfnot..than
e. o O five hundred dollars($500),
nl.as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ•FI'. STORIES - TYPE CONS'TRUC'TION
�Z compensation,wtildothe work.and thestrocture is not intended or offered for
p sale(Sec.7094,Business and Professions Code:The Contractors License law
$ does not apply to an owner of property who Wilds or Improves thereon,and - OCC.GROUP RIS.UNITS
who does such work himself orthrough his own employees,provided that such
Improvements are not intended or offered for sale.If,howeveq the building or TOTAL:
impmvereent bsold with in one yi a rof completion,the owner-W ilderwill have
th�rden of proving that he did not build or improve for purpose of sale.). QTY.
PLUMBING PERMIT FEE FD ZONE ApNr
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Professlons Cde:
The Contractor's License Law docs net apply to an owner of property who pLTQt-DRAIN Xa VFM-WATER(EA)
builds or improves thereon, and who contrafor such plojoes with a - FEE SUMMARY
oft
151 Bcenwd pursuant to the Contader's License Law. BACK FLOW PROTECT.DEVICE
1__I I am exempt under Sec. B k P C for this reason "TTTSIDE FEES
DRAINS FLOOR,ROOF,AREA,COND.
SANITARY Y_ N_ -
Owner Date RECFIFf X
WORKMAN COMPEWSATION cateofDECLARATIONconsent
FIXTORPS PER TRAP SCHOOL TAX Y_ N
❑1 hereby affirm that 1 have a Inumine of consent to self-insure,thereof
ora RECEIPT N
certi(late o(Werken Compensatlonlvuranceo rtlRed copy thereo((Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FTE Y N
3800,GbCJ ,�G y RECEIPT _
I'oliryp
GAS, GI-
EA.SYSTOVER4(FA)
Com anv (1 tet 4 Buaomc DrvlsioN Fees
Certified copy hereby tumbhed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certsed copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SL'1VEWSANITARY-STORM EA 20017f Date Recei tll
(fhb section need nn bo completed Bihe permiYis for one hundred dollars
($1ul
I oeWATER HEATIRW/VENT/ELECTR ENERGY FEE Y_ N_
rtPerformanceb issued,In the Performance of thework for which this permit sed,
I shall not employ any person In any manner so as to become subject to the WAT M SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei tit
Z O NOTICE TO APPLICANT:R,after making this Certificate of Exemption,you
Fshould become subject to the Workeri Compensation provisions or the Labor TOTAL:
N Code,you most forthwith comply with such provblov milds permit shall be BUILDING FEE
W > deemed revokd.
CONSTRUCTION LENDING AGENCY SEISMIC FEE O
CL Ihereby affirm that there is a constaction lending agency for the perform ELECTRIC FEE
7 Z anceoftheworkforwhichihis permit is Issued(Sec,3097,Civ.C.) TOTAL:
02 Lenders Name PLUMBING FEE
LL f Lenice.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iredify that l have read this appliationand etatethattheah. iof.motien
a is correct.l agree to comply with all city and county ordinancesand state laws PERMIT ISSUANCE FEES PAID:
>. relztingto Wilding construction,and herebyawhortm representatives efthta
Zcity to enter upon the above-mentioned property for inspection purposes. ALTFRORADDTOMECH. D2IC Reeciptq
(We)agree to save,indemnify an d krep harmless the City of Cupertino AIR HANDLING UNIT(f010,000 CFM)
V ag�lnstliabilitics,jadgnenb, ndexpenseswh hmaylnanywayaccrue SUBTOTAL:
Y;=
instaaid Chyinconxquen of egr ting 1.permit.
/�� AIR ILANDUNG UhTf(OVM 10,000C III
CONSTRUCTION TAX
Primate of Applicant/Contractor Dal!/ EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSU E
Will theappllant or future b1ldIng occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recel tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cde�'Stmti1I 2(a)i HEATING UNIT(OVER 100,000 BU) TOTAL: O
nYo futuff VENTILATION FAN(SINGLE:RFSID) ' ISSUANCE DATE
Will the applicant orrfuture building occupant use equipment or devices
which emit hav Hous air contaminants as defined by the Bay Area Air '
Quality Management Distrix BOILER-COMP OL-E'OR IW,"BM
4PAID,Ycs L—"J/ ID,
havercadtheha carCusrtatcria qulrenentsunderChapter6.95mf O GR-COMP 100,000BTV) PA
the California Health&Safety Code,Sections 25505,25533and25534.1 „, �O(]il '
understand that ifthebulldingdoesnotcurrentlyhaveatenant,that It Is NEW RESIDENTIAL MECH. 7 SQ.Ff. I,��fll� j JV
responsibility to notify the occupant of the mqubememe which most be met
Ori to issuance of a Certificate of O an " .
I` CItV fIf C❑rapj'in0
Own or authorized agent Pate1
TOTAL ISSUED BY:
OFFICE COPY