19534 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prdecl Identification PERMIT NO.
Building Address.
26(obs 19534
�A Name. Phone: - - - APPLICATIUNbUbMil IM,UAlh
CITYOFCUPERTTNO-BUILDING DIVISION O
Contr shame:- Lic.No: APPLICATION / PERMIT 7 '
A BUILDINGELECMCAI PLUMBING-MECHAMCAL CATEGORY CONTROL NT-S_2
l A y oM` 1i-1�1 QTY ELECTRIC PERMIT". FEE 'BUILDING-PERMITINFO '
Address: 40 / -
PERh4TIS5UANCE FW
LIZ ❑ ElLICENSEDCONie S CLAR TION - L7 .
Thereby affirnthatlam under licensed under provolone of Chapter9(commenc APPUANCESRPSIDEFITIAL JOB DESCRB'TION
ingwith Section 7000)of Dlvision3ofthe Buslnessand ProfessinesCode,and my
license is In full force and effect. sT.l Fi PANELS
Limnsc Lic.p �/- 7-
Date Contractor � Cji
ARCHITECTS DE IARATION 201.100OAMPS
W I understanAisyfpUroshaB be used upubac remrda OVER IOW AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
qqF+ O �
k�LJ�j Licensed Prolc.slonalSIGNS ELECTRICAL
<6w OWNER-BUILDER DECLARATION
sl'i Fn
Iheretim y aflrthat am exempt from the Cont ractor'a License Law for the SPEGIALCIRCUIT/MLSC '
O
lellowing reason.(Section 70315,Business and Professions Code:Any city or s: TIME.METER OR POLE INST.
countywhich requlresa permit tomro requiresth,impmvent fors ch,arrepalr
C �a le awrnare priontostatement
t that
he is also pestheat to the
forsuc.perMtm - POWER DEVICES
PJ O +1 file a signed statement ( he t Bcenaed pursuant it the pro7000)of the
�Oy Cnntractars License law(Cha erg(commencing with Section 7000)of Divi.Yrs B Pt SWIMMINGPOOL ELECTRIC VALUATION Ve D
,�05 slon3ofthe Busmessand ProfeasbraCode)orthat heoexem themfmmand /'
S" the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTUItES 0 0 U _
applicant for a permit subjects the applicant to a civil penalty of not more than
n. o O five hundred dollars(&500).
m NEW RESIDENTIAL ELFfTR SQ.FI. ES TYPE CONSTRUCTION
.. �I,eaowner of the property,or my employees ofwith in wagn as offered
sole
C�.Q wIn&,tion,wWdothe workandthe structure C.errandedor...Lw
❑ sale(Sec. ppy to an ower of Pmf
Code:Wids or improves
Uceme Law
docs not apply to an owner of property who Wilds or Improves(hereon,and .DCC.GROUP RES.UNITS
whodeessuchwarkhimself wthrough hlsownemployees,providedthatwch
impmvemeno are not Intended oroffered for sale.1(howevep thebuilding or TOTAL:
Improvement oaold withinoneyearofcwnpletiomtheowner-W OderwBl have
th rden of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
"I,as owner of the property,am exclusively contracting with licensed -
conlractomtoconstructtheproject(Sec 70"Business and Profcedons Code: PERMITISSUANCE
The Contractor's Llcenx Law does not apply to an owner of property,who
Wilds or Improves thereon,and who contracts for such ptojeea with a ALTER-DRAIN 1,VENT-WATER(EM _
on,1Ltt{(actor(s)Ilm..d pursuant to the Cmntomeer'e License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B& P C for this reconOUTSIDEFEES
DRAINS FLOOR A,ROOF,AREGOND. SANITARY Y_ N_
Owner Date RECEIPT X
WORIONAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI IDOL TAX Y N
❑I hereby affirm that I have'a certificate of consent to self-insure,or a RECEIPT N
certificate ofWorken'Compensation Imurarmora certified copy theroof(See. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y ' N '
3800,Lab C.) RECEIPT N
PdIry X GAS EA.SYSTEM-0VER 4(EA)
Com a • BUILDING DIVISION FEES
�Cny erufted copy is hrebytumllcl GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F—ICerttfied copy o filed with the city Inspection division. €�
CERTIFICATE OF EXEMPTION(FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2WFT Date Recei t#
(rhisseCion need not W completed Ilthe permit o forone hundred dollars
(8100)orless.) WATFRIff.ATER W/VENT/F].ECTR ENERGY FEE Y_ N_
I certRy that In the performance of the work for which this permit is Word, -
I shall not employ any person in any manner so as to become s i to the WATER workers Compensation Law.of California..Date PAID
Applicant ' Date Recei t#
Z NEW RESIDENTIAL PLMB. SQ.FI'.
ZO NOTICEco APPLICAMhe cher maWomperation cateof Exemption,you
should become subject to the Worken'Comperwtlon provision of the Labor TOTAL:
W Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE .OD
W j deamcd revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffirmthat there Is a construction lendingagency forthe perform TOTAL: ELECTRIC FEE
D Z anceofthework torwhich o permit o lcved(Sec.30Y/,Civ.C.)
02 lender.Name /� PLUMBING FEE
LLT LendersAddre.�/ QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
O WIudifythatlhaveredthoappBaUonandaatethattheabove information PEES PAID:
a acorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE
:a. (L to building construction,and hereby authorize representatives ofthis
F N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH.
Z (We)agree to.ave,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V ago bot liabilities,ydgmenta,roma a cad expenses which may in any way,meme AIR TIANDLING UNIT(TO 10,00)CFM) • SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HA NDLINC MIT(OVER I O,OOD CFM) CONSTRUCTION TAX
Signature of Applicant/Contoitmr Dam EXMUSTHOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfumre building occupant store or handle haaardous HEATING UNIT(TO 100,e00 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I ealth and Safety Code Section 25532(x)? HEATING UNIT(OVM I0%XX BTU) TOTAL: eVF,
Yes L_I No
Will the applicant orfuhimbuilding ocmpantuse equipment or devices VENTILATION FAN(SINGLE RPSID) ISSUANCE DATE
which emit ban rdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3I1P OR 100,000 BTU)
4Yes ❑No ,
have read the hazallous materials requirements under Chapter 6.95 oL BOILER-COMP(OVER100,000 BTU)
the Cahfomia health&SafetyCode,Soclom,25505,25533 and 255M.I
understand that lithe Wilding does not ni ently have a tenant,that it is my NEWRENDENTIALMECIL SQ.FT.
nspos' ility to notify the occupant of the requirements which most be mel n ryO
P rior to uanceofa Certilkateof ompanry. p��_C(
Ow r authorised ager
TOTAL ISSUEDBY7y�
;e1
OFFICE COPY