21809 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER.MITNO.
Building Address:
19
000 f-EowtL-sT"-6 2
1809
o _
ars e, A A
Slts�1AEy[S 257-791,�� CITY OF CUPERTINO-BUILDING DIVISION —�^q
Contra"°:°Name: Lie.No, APPLICATION / PERMIT I
N r C�r CATEGORY CON
TIS SING-MECHAMCAL 'IJIC]1,M/
A chile"/G r. s� Llc No: eV
11J`aaa Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: IJL� air
pERMITISSUANCE 2� ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provLdoru o(Chapter9(rommmc AI'PWANCESRESIDENTIAL ) ,
ing with Section 7000)of Division 3 ofthe Business and ProfeslonsCode,and my C/
license Is In full force and died. PANELS -s
Cla® LIL
Date ConY I
Date tracmr Iters rTR'txl
ARCHITECTS DECLARATION 201-1000AMPS
047 00 I understand my plans shaR be uwd a public mc°nls. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
() Lkrensed Pearatelmal SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIAL CIRC[RT/MLSC
s 7, Thereby a(llrmtFutlam exemptfromthe Contradoes Lk nwe wforthe
following reason.(Section 7m1S,Business and Professions Code:Any city or
O .t.R TEMP.METER OR POLE INS!.
P4 .7 county rcqulrcsaperMt to corotruc"teq improve,demollsh,or repair
any structure prior to 1,Issuance,also requim the applicant for such permit to POWER DEVICES
O w file a signed statement that he U licensed pursuant to the provisions of the
w� Contractor's License Law(Chapter 9(commencing with Section""I)ofDivi-
3 OSWIMMING BOOL ELECTRIC
slon3 of the Busmenend Pro(embru Code)orthat hela exempt therefromand VALUATION
y-' the basis for the alleged exemption. Any violation of Section 7611-5 by any
<5 applicant fora permitsubjelutheapplimm to a civil penalty of net more than OUTLETSSWITCHESHXTURFS ,l
t, to fvc hundred dollars($SM. NEW RESIDENTIAL ELECTR
Q I,as owner of the ro e'f7�' SCOWFS IYI'E CONSIRIlCT10N
2 e party,or he amp m n with wages a their sole ` x
C < compensation,Business and roxessmsCdurehe C..tended oroflemlw
��D sale(Sec.7064,Business and Professlov Code.The Contractors Llceve Taw 'V
[�j$$ does not apply to an owner of property who Wilda or improve thereon andUNITS
O QS �x� l7CC._CROUP RES.
0.0.
who doessuch work himself orthrough his own employee,provided that such
Improvements are not intended oroffered for sale.If,however,thebuilding or TOTAL;
improvement Lssoldwithlnomyearofcompldlorytheawner-bullderwill have
hetden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD2ANE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE ("') .�
tractors to construct the project(Sec.7044,Business and Prvfessbm Code: C
Eo Ienmm'a Lirenee Taw does nest apply to an owner of property who ALTER-DRAIN k VEM-WATER(EA)
bu Rds or Improves thereon,and who emoncts for such pt,ojeds with a
�gN(+ctor(s)licenacd pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOG SANITARY Y_ N
. Owner Date R ROOF,AREA,GOND. RECEIPT 0
WORK MAN COMPENSATION DECLARATION FE(7VRFS-MR TRAP IDOL TAX Y_ N_
❑1 hereby affirmorken that I have o Insurance
of consent to self-hours,or RECEIPT I
MM,Lcerlificate,ofbC.Worken'Comperuation lruuranre ora certified copy thereof(Sac. GAS EA.SYSTEM-1 INCA OUTLETS PARC FEE Y N
3800.Lab Cd
Polky If RECEIPT If
Co any GAS EA.SYSTEM-OVER 4(EA)
ff CertNed copy la hereby famished. BUILDING DI VISION FEES
❑Certified copy is filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF UMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE - I
(Thissection need tm be completed if the permit isforone hundred dollars SEWER-SANITARY-STORM EA.2WF1'. Ddfe RL i [#
($1 W)orlen.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cent that o the performance of the work sor s to
this permit istothissued,
I shall not employ an/person f any manner at at to beronn subject to the WA.�SYSTEM/TREATING
Workers'Compensation laws of California. Data. PAID
O Z Applicant
NEW RESIDENTIAL PLMB. Dale RCcei t#
O NOTlCETOAPPLICt to
akar rsi Co pen ationlcateof Exemption,you ��
I'- Code,shoulYou
bommoaforth it the Workers'Compensation porthis permita of s Labor Cr-0 �.C. D TOTAL:
WW Code you mus[forthwilh comply with such provision orthla permit shall be 1�� J
j deemed rev°ked. �� BUILDING EE 1 eb
a p CONSTRUCTION LENDING AGENCY I P I SEISMIC FEE k
Thereby affirmthat there V a construction lending agency for the perform 'ys 6LGCTRIC FEB
7 Z
an 'of the work for which this permit is Issued(Sm.3097,Civ.C.) TOTAL: I `-D
(� O 1<nder's Name l PLUMBING FEE QQ
LL F Ie der'SAddren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1omlfythatl have read lhlsappRmtionand state thattheabove mmornatinn
Isecrnxe.Iagree to comply with all city and county ordmances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building ror)gtmctmn,and hereby authorize reprnenlatives of(his
F Z city to enter upon the above.mentmned property for inspection purpose. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgment,mansard expense which In any wayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL-
'erriTdGity In consequence of the grantingd it.
�J1 tJl AIR HANDLING UNIT'(OVER iq"Cr.M) CONSTRUCTION TAX
ig reo AppBeant/Contra or - Data O(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplicant or town,building occopant store or handle hazardous HEATING UNIT CIT,100,ODO BTU)
terlalasdefined by the Cupertino Municipal Code,Chapter 9.12,and the Date RKel t#
Ik^nhh,�an SafetyCede Sedion25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
lam'*°9 M No
Will theappilcant nefume building occupant use equipment mdevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air coal aminant,as defined by the Bay Area Air _
Quality Management DisMd7 BOILER-COMP PHP OR 100,000 BTU)
havereed the hazer smamdals Sections
under Chapter.1 of BOILER-COMP(OV[R 100,000 IT
the Callfomla lielth&Sa(dy Corte,Sedlora 25505,25533 and 2Si74.1
underslandthatifthe building docs not corrcnlly ave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT IS�' 1991
resporolbl,tytondBythcoccupantoltherequ mentswhiehrrwstbemt ca3
Issuance aCa"Ifimeref Oc pa
J
nerorauthodzed gent Data
TOTAL: JISSUEDBY
OFFICE COPY