19597 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PExwTNO.
Building AddtLss: 1 9597
nereme: �_ Ph pA AM
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a,�-�js CITYOFCUPERTIN0.6UILDING DIVISION
centndor sine. LIeNo: . APPLICATION I PERMIT ( — 3 — [c,
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BUILDING-ELECTRICALPLUMBINC.MECHANICAL CATECARY CONTROL X
Architect/Engineer. LIc.N.
�- -QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERhITISSUANCE O a ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l ace lcensed under provisions of Chapler9(mmmer APPUANCFSRESIDENML JOBDE5CRIPHON
licInensei Section force and ductn3ofthe Businessand ProfessionsCode,and my
License
is full force end effect PANELS UP TO 2�AMPS /�� ��{
License Casa Lk.M 'Z-� SQ` c.,"' e
Date —ContractorARCHITECTS
201 IOMAMPS 1"--�Fll
ARCHITECTSDECLARATION OVFRIOOOAMPS FT FLOOR AREA g/SQ FT
0 O I understand my plain shall be used as public records �`'
IvJ 06 Licensed Professional SIGNS ELECTRICAL
6 W OWNER-BUILDER DECLARATION
`N SPECIALCIRCIIIT/MISC
Hurchyaffir'awingrvxx.mtbmlam esempt(romthe Contractorb Limnse law for the
lo0owing recon.(SMlon 70315,Business and Professions Code:Any dtyor
t-4 .a tywhkhrequirnapermittomnstmd,alter, pmve,dem lLsh,orrepalr TEMP.MEIER OR POLE INST.
anystmctumpdorto166wancgalsorequirestheappbuntformchpermitto
U file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
O7ro[- Contractor's License Law(Chapter 9(commencing with Section 7000)of DWI.
F OS slon3ofthe Businessand ProfmiomCode)orthatheisexemFrtihemfmmand SWIrfMINC POOL ELECTRIC VALUATION
^5 Gthe basis for the alleged exemption. Any violation of Section 70312 by any 0[TILETSSWITCIiFSHJ(NREB
Oapplicant for a permit subjects the applicant to a civil penalty of not more than
o Ivc hI as
owndoler
of thepr. NEW RESIDENTIAL ELECTR SQFF. TYPE CONSTRUCTION
l=7¢ I as owner of the property,or he employees with wages r their sole
compo atlon,willdothe work and the stmdure Is not Intended or offered for
5 O sale(Sec.7044,Busteassand Professions Code:The Contractor's Lirense Law
docs not apply to an owner of property who builds or improves thereon,and OCC.CROUP REAUNI'I'S
0. whodce suchworkhirtcselforthroughhisownemployees,providedthatsuch
Improvements arena intended mediated(orsale.If,hmveveg thebullding or TOTAL:
Improvement issold withinoneyearofcompleiomtheowner-Wlderwill have -
tliburdenofprovingthathedidnotbuRdorImprove for purpose of sale.). QTy. PLUMBING PERMIT FEE FLCODZONE APN _
u L as owner or the property,am exclusively contracting with licensed PERMIT ISSUANCE
to camtruct the project(Ser.7014,Business and professions Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, -
on,and who contrafor such ploje
a with a FEESUMMARYc irador(s)licensed pursuant to the Comractore License Law. BACK FLOW PROTECT.DEVICE
❑I avempt uMerp // iA 6.D'C !or this mason '
t �• '��p'���1 /' -' DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT
Ter / T —
WORKMAJ+ OMPEN ATION DECLARATION PD(TURES PER TRAP SCHOOLTAX Y N
❑I hereby affirm that r have o certificateInsurance
of consent to copy
theroo ora RECEIPT R
certificate of Worken'Compensationlnsurance ora certl(kd ropy thereof6ec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
38110.Lab C.) RECEIPT X
Poliry p GAS EA.SY5TEM-OVER 4(EA)
Com any BUILDING DI VISION FE I'S
Ce
copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CenlRed copy 6 riled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA:200FT. DdIC Receipt#
(This action need not be completed if the pemut is forom hundred dollars
(51 I0)orlessJ WATERHM=W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that o the performance oftheworkm manner
so as to b this penult c issued,
I shat not employ any person In any manner ro as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation law.of California. Date PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recti t#
Z O NOTICE TO APPLICANT:If,aftar making this Certificate of arreptloq you
should besubpe,to the Worke 'Compensatbn provision of the Labor TOTAL:
CC nne m
W Code,you=at fothwith comply with such provisions or this permit shall be BUILDING FEE
W > deemed revoked. .
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Rl Z Thereby work
for whhereisamntmctlon lending agency .C.) perform- ELECTRIC FEE
7 Z are"of Name
for which this permit Is Issued(Sec.3097,Civ.C.)
TOTAL:
U O IcndersName PLUMBING PEE
I- Lenders Address QTY. MECHANICAL PERMIT FEE
LL' U Icetifythatl have read this appliestionand statethat theabove Information MECHANICAL FEE
O W noormet.l agreetocomplywith all dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} a relating to building oonstmction,and hereby authorbee representatives ofthis
N F d to entero n the above.mentioned for inspection a ALTERORADDTOMECH.Z city upon keep p rpO9e9' Date Receipt#
(We)agree to save,indemnity and kkeep harmless the City of Cupertino
V againsHabllltks,jtdgmenb,cos�and expenses which may In anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
told ity.arro,xasuctueocualf min ofthlspernit.
AIR Hwn'DUlvc unTr rovFR lo,00B CEM) CONSTRUCTION TAX
-- SigntuDaof"A phcam/ ontrator Dine EXHA.15THODD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle harardous HFEXTING UNIT(TO 100,000 BM Date RCcei [#
natural as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER IM,000 BTU) TOTAL:
` ❑Y. M No -
Willlheapplicantorfutue Wildingoccvpont use equipment ordevices VENTILATION FAN(SINGLE REBID) I$J ��yF-4ATE
which emit hacardous air metacurame as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4Yca No
❑havereadtheh mootmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000BTU) t ql !
the California Health&SafetyCode,Sections 25505,25533 and 25534.1 -e1i �"''tdI
understand that it the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQ.FT
responsibility to notify the occupant of the requvements which must be mat Cd{ty�b}%ROPxhNRO
prior to Issuance of a Certificate of Occupancy. NU{L�a/VIP
Owner or authorized agent Date TSSUfiD BY:
TOTAL:
OFFICE COPY