19478 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Ii Nei. WentlRration - PFXWTNO.
Building Address:
2072 'v v- 19478
Phone. A
rcr. .n,er CITY OF CUPERTINO-BUILDING DIVISION -
Contarterb Name: li � Z41- I�aj3 LIt.ivm APPLICATION /PERMIT a 0
^ 27-'9
BUILDING-ELECDUCA4PLUMBINGMEQNMCAL CATEGORY CONTROL(
Are I
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
. Add.
LICENSEUCONTRACTOR'SDECLARATION I'FRtATI55UANCP >q ❑ ❑ ❑
I hereby aRirm m that l alicensed under providons of Chapter 9(oarement APPLIANCFSRESIDENf1AL - \� JOB DESZRIPTIDN
ingwith Sectlon7000).(Deeider3.fthell".and ProfessonsC deny
license is In full for¢and effect. PANELS `
Date
Date —Contractor UP TO 2DO ANIPSI U Y
ARCHRECI'S DECLARATION 201-1000 AMPS
rc0 Z deo e is JuB b ;;; ss pubht Tec OVER 1000 AMPS SQ.FT.FLOOR AREA $ISQ.FT.
rOr. SIGNS ELFL7RICA
Ti LI¢rsd Pdessbnal
�«<'��-uu�ll OWNER-BUILDER DECLARATION VCERCLT1TjS4k
7i.., , thereby afflrenthat l am exempt fromtheCoe, coraLltrroeLawfw thefollowing renin.(Seed.71315,Businessad Profubna Code My sty oNSF.
muntywhkhrequMapen wmr ctr alter,lmpr ,derrolbh,oi repaimdtlOUfile a signed dement that he b hocrsed pumuant to the pmvlateresof the -
Contractor'sLkerue Law(Chapter9(mmmencing with Sen1on 70M)of Did- •VALUATI,kn3oftheBuN mandPdessbruC.de)orthathel. re pthercfromad �the boob(or[he alleged eaempbn. Any vlolalbn of SMbn 78715 by any D D
appUmm fora perMt subjecti the applicant to a cb,l penalty,d not more than
Rve undmd dollu,lS+DU1. -
6I,as owner of the property,or my employees whh wages as their rose
NEW RF5IDENT[AL SQ}T. SIDRI TYPE CONSTRUCTION
compere rdon,will do the work,and the rtrutlure is not Intended or offend for
Osale Etc 70K Buelness and Professions Code The Contractor,Lime Law
i� does not apply to an owner of property who builds or lmproso thereon,and
who does such work himself or through his own employees,pmvldd that such OCC.GROUP RFS((NITS
improvements are not Intended oroffered for sale.If,however,the building or a TOTAL
Improvtn Mn "dor hlnomyeardcmtplelb theowner-bullderw ve
L" enofpmdngthathedldm Hdoriffywefmpurpoaeof,ale.). QTY. PLUMBING PERMIT .FEE
Lj L as owner of the Property,am eachuhNm
y ntraeling with Ikensed FLOOD ZONE APN
PFRMITISSUANCE
contract.to construct the project(Sre 7074,B.,ineaand Pdeabm Code:
The Contractor's Lkzrse Law does not apply to an owner of property who ALM-DRAIN k VEM-WATER(EN
Wor Impnao thereon,and who eantram m for such projewith a
ctorW B¢n ed punuant to the Contractors Lkenae law. FEE SUMMARY
Lj I am exempt under Sue B k P C /or this eea+.n
BACK FLAW PROTECT.DEVICE
Owner Date DRAINS'FLOOR ROOF,AREA,GOND. SANITARY Y N_
RECEIPT#
WOR M
KAN COMPENSATION SATN DECLARATION FDfTVRFS PER TRAP SQTOIX.TAX Y_ N_
❑I hereby affirm that I have•¢rtlBate of canuenl to self-Insure,¢a
RFL- NI
mrtRiate sfW.rken'Cmnprrsatlon Imuran¢or.¢nifled copy there.ff5ec GAS FA.SYSTEM-1 INCA OUT1,EIS PARKFEE Y N
3300,Lab C.) —
RECEIPT I
Policy# GAS F.A.SYSTEM-OVER 4(EA)
Com cry BUILDING DIVISION FEES
r7ertNd ropy is hereby furnished. GREASE/INDUSIRI.WASTE INTERCEPTOR PTIANGHECK FEE
Certified ropy b filedwith the city inspecikn dlvblon.
CERTIFICATE OF EXETIPTION FROM WORKERS GREASE TRV' PAID
COMPENSATION INSURANCE gWER SANITARY STORM EA.31�T Date RLYYI t#
(TMs aedbn n¢d not becompleted Lithe permit b(w ore hundred dollar,
W00)orless') WATER HFATFRwivFLai'/fL.EcrR ENE•RGYFEE Y N_
I certlfythat in the performance of the work forwhIeh this pemord
dt i,l ,
1 sha0 not employ any person In any manner m as to become subjed to the WATER SYSIflNRAPATING
Workers Campensatbn law,of Callfurnla.Date PAID
O Z Appbant NEW RESIDENTIAL PLMB. SQ-ET Date Recei tit
Z O N =,TO APPLICANf:If,after making this CertBivte of Ea,mptbn,you
shoddb nne,ubjectto the Workbb
ers'Compereation provns.fthe Labor TOTAL
M N Code,you trust forthwith comply with such prevbbro or this Permit shell Im QUILOING FEE
3�.lI
W ] deened rnokd. -
CONSTRUCTION LENDIIJGAGHgcn IMI FEE
S f] herebyaffirm
htchthb mrmtr.m.nlendmgag7, cert),perform- ELECTRIC FEE
7 Z send&, area, (.r which this ptmdtbbsnd(Sec 307/, Iv.CJ TOTAL:
() O Iedtr'a Name • . PLUMBING FEE
LLE- lendre,Aadmn QTY. MECHANICAL PERMIT FE8 MECHANICAL FEE
Irertffythrtl have read thbappllalbn and stalelhd the above information
O W
a loin.srre
ect.(agtommplywLLhaBdtyaMc ntyordL nmandeatelaws PERMIT ISSUANCE FEES PAID,.r relating tobMking mvtmrtlon,and hereby authorfre represenmwea ofthla
I_ N cky to emerup.n the abovomentbiud property,forlropedbn purpose. ALTER OR ADD TO MECH.
_ (We)agree to save Indemnify an d keep harmless the City of Cupertino Date Receipt#
() agawt habWcles,prigmems,cnalsard expenses which may lnanyway.. AIR HANDLING UNIT(TO 10,0)0 CM) SUBTOTAL:
against said City I.mnsequerce of the gaming of this pemW. AIR HANDLING UNIT(OVER 10,Il0OCFM) CONSTRUCTION TAX
Sigwmreef AppuamfConiractw Date EXHAUSTHOOD(WfDUCI) CONSTRUCTION TAX PAID:
HAURUOUSMATERIALSDISCLOSURE t
Will theapp0¢ntorfulure building otvtpaet Mo.orhaMle harAndous HEATING UNIT(TO 100,ODO BTL!) Date Recel tM
material as deBred by the Cupertiro MunddpaI Cade,Chapter 9.1 3,and the
rleahh adSafety Code Section 25533G)7 HEATING UNIT(OVER IW,=BTU) TOTAL: es
E]Yes M No
Will the applicant or future bu llding o¢upant use equipment or devim V ENTILATION FAN(SINGLE RESID) ISSUAeC''+DI�TE
which emit bunrdos ab conumirums as deOnud by the Bay Area Air
Quality Mevgereent DbtrktT B0I1,ER-COMP(3HP OR 100,0(3 BTU) -
Yen F I No
Ihavereadtheblup, arWedaisrequirennnbunderChapler69Sof BOILER-COMP(OVER100,000 ITT U) YpO 2199Q
the Gllfwma Heakh k Safety Code,Sectlow 255OS,355]3 and 25536.I N
uderataM Nat if the bu0dingdoer wt amently haveatenanL that itbmy NEW RESIDENTUL M1fECIi. SQ.FT
responsibility to notify the occupant of the requirements which must be met City,,of n!ncs rr
pri.rmissuawe ofaCertifleteof0ceupamy. ^^yy�� �al�aPF ��u�..�..
Owner or authorized agent Date ISSUEDBY:JC•6r
TOTAL
OFFICE COPY