19837 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification PERMIT NO.
Building Address: 19837/13
neva Name. Phone: A A A
CITY OF CUPERTINO-BUILDING DIVISION
att.raName: Lie.No APPLICATION I PERMIT "� l
a /.t/0 CATEGORY CONTROL#
Architett/Engine r: Lie.No. BUILDINGELECTRICALPLUMBING-MECHANICAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
i ,ryS�
2+ Address PERMITISSUANCE 12{-,V � �^
LICENSED,CONTRACTOR'S DECLARATION �-s�
I hereby fioomnthat l amlkensodunder hethis essalonsof ChfixisC(mmmmc MPWANCESRESIDENTIAL �W JOB DESCRRTION
Ingwith5ection 7000)01 Divlslon3o(the8usinssand Pro@aelonsCode,and my
' license is In ful ddfect �f p PANELS
LicensO Cuss Lic.N 17(� (
Date_ ontractor �CC
ARCHITECT Cr ON 701-IODOAMPS
�q+rep ZO 7 understand my plans shah be used ss politic a. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
i4 Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
r
7, 1 hereby affirm that lam exempt from the Contractors License Law for the
qp following reason.(Section 70715,Business and Professions Code:My city or
OR—
cmntywhichrequimaper ttomrutmd,alter,impmvGdem ltsh,orrepalr TEMP.METER OR POLE INST.
anystmmmpriortoitsbmance,aborequimatheappliantforsuchper tto
3 n. file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
u, Contractor's License Law(Chapter 9(commencing with Section 7000)of DIVI- SWIMMING POOL ELECTRIC
i..,fSOs s1on3 ofthe Business and Profession Code)orthat he is exempttherefromand VALUATIOAL
6 the basis for the alleged exemption. Any violation of Section 7MI-5 by any OUTLETSSWITCHESFfX'NRES �x(�j ��qq C3-
app8cant fora permit subjeRs theappecam to a civil penalty of not more than �L�C,.JQ
gg Ove h1,as odnerWshe pr). NEW RESIDENTIAL ELEC7R
p-.�n ❑I,as ower of the property,or my employees with wages as their sole �3'T STORIES TYPE CONSTRUCTION
compensation,w0ldo the work,and the structure Is not intended or offend for
$,J O sole(Sec.7094,Busioussand Professions Code:The Contractors Limme law
fd$$ does not apply to an owner of property who builds or improves,thermn,and
0.0. who doeasuchwork himselforlhrough his own employees,provided that such � ��qs9Rf OCG GROUP' RES.UMTS
improvementsarenot intended oroffered forsale.If,however the building or TOTAL:24c-C.! P_
Improvement hand within.neyearofcompletion,theowner-b Oderwill have
t rdenofprovingthat he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE 01000 pANp APN
L as owner tr the property,(Sm.70K
Business
contracting with licensed PERMR ISSUANCE
TheconCo tr ieo construct the project(Sec.appy Business and of property
Code:
The C.ntrampr o es th a Law aces not apply to an owner of property who ALTER (pA)
bullas c7litFicto Improve thereon, and who mnencta for such p(ojects with a DRAiN&VENT
or(sexempt under ant Sm
the Contractors License law. BACK FLAW PROTECT.DEVICE FEE SUMMARY
I am exempt under See B&P C for this reason
CUTS]OF -
Owner Date DRAINFLOOR ROOF,AREA,COND. SANITARY Y_ N
S
WORKMAN COMPENSATION DECLARATIONREC I T#
❑ affirm
I hereby that I have a rertlBcate of consent to self-insure,or a mTuius.PERTRAP SCHOOL TAX Y N
certificate of Workers'Compensatl.n Insurance or a certified ropythere.f(Sec. RECER'T N
3800, #b �,�5 GAS EA.SYSTEM.1 INC.4 OUTTF1'S PARK FEE Y N_
RECEIPT N
Com anv� S'TjrfT GAS EA.SYSTEM-0VERd(EA)
a ,❑�P�Cemlf py Is barely rm.hea. BUILDING DIVISION FEES
mpy in filed with the city inspection division. GREASE/NDUSIRI,WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF F)(EMPTION FROM WORKERS' GREASE TRAP PAID r�
INSURANCE SEWERSANITARYSTORM EA 200FT Date Recei t#
(ThlssectnotCOMPENSATIONbcion need not be completed lithe permit V for ane hundred dollars
($100)or less.)
I mmifythat in the performance ofthe work for Which this permit is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N
10-11 non employ any person in any manner ro u to become subject to the
WOrken'Compensauon law..(GII(omia.Date WATER SYSTEM/TREATING
O Z Appileant PAID
Z O NOTICE TO APPLICAM:I(,aper making eWs CemBlcate o(Excmption,you NEW RESIDENTIAL PLMB.__SQFT. Date Recei t#
F N should
id become aubjM to the Workers'Comprns
eatlm provisions of the Labor TOTAL:
, with such provklora mthia pshal
permit l be
W > Codeyou most forthwith cempty deemed revoked. BUILDING FEE
ll O CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I hereby affirm that there b
Is.construction lending agency for the perform, TOTAL: 'l�ance of the work for which this permit is Issued(Sec.3097,Civ.C.) _l
LL O lender's Name ELECTRIC FEE co
PLUMBINGFEE se0
0 F Lender'.iAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irertlfythatl have read this appacaucnand statethatthe above Infomretion ^ /yc
a Jammed.Iagree to comply with all city and county ordinances and state laws PERMITI.SSUANCE � 4`"" FEES PAID:
} N relatingtobitkiingmneuuctlon,aM herebyauthorize mpresentativesofthis
F Z city to enter upon the above-mentionad propertyfor inspection purposes. ALTER OR ADDTO MECH.
_ (We)agree ro save,Indemnify an d keep barmien the City of Cupemmo Date Receipt#
agaWtllabititin,ydgmenb,coetaandexpenseawhich maylnanywayamrne AIRHANDLING UNIT(rOt0,000CFM) SUBTOTAL'
against said City in consequence of the granting of this Ferri,
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) 2sC� CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE l
Will the applicant or future building occupant store or hand Is h.m., HEATING UNIT(TO 100,(00 BIT)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Recei t#
health and Safety Code Section 25532(a)2 HEATING UNIT(OVER I W,030 BTU)
❑ Yea M No TOTAL:
Willtheapplicent or fummbuileingoccupantussequipment ordevicesM
(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
ality Management District? OR TOO,"BTU)
c,Ye. No
have re.dthehaza sus materialsmquimr ntsu,der Chap,er6.15 ofER 100,000610)the Glifomla Health&Safety Code,Sections 25505,25533 and 2S536.I
understand th if lilytheocBitindocs not mmently haveaienantthat itmmyMETH. SQFT. Otohebo
bait to ai(y theoc ipant of the requirement,which must be met �) (im (�'pri to lssua ce aCertific. co(Omrpancy.or authotlee ag t Date
TOTAL: I�s(`�' ISSUED BY:
OFFICE COPY