19457 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
11 in A°i; 19457
sonars as Phone: APPLICA A
.•. /[� CITY OF CUPERTINO-BUILDING DIVISION
• G° r Lie.No: APPLICATION / PERMIT —�\Cto
rte
Llc.No: BUILDING-ELECTRICALPLUMBING-MECIIAMCAL CATEGORY CONTROL M
Arehitm/Engines
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE ❑ ❑ ❑
LICENSED I a CONTRACTOR'S DECLARATION
I herebySectio70Wtlaiv Bcemaedunder provisions ofChionsCoe,and(common on
APPLIANCES JO UC IU1'1'ION
In ease I Semon force ofd deon3oHhe Buslnenand ProleasionsCode,and my
ummee b m sou rmme dna erten. PANUS
License Cla® Contractor—
Ia)
Date Contractor
ARCHITECTS DECLARATION 201-IOD)AMPS
q�v 0 7O I understand my plans shall be used m public records OVER IrJO AMPS SQ.FT.FLOOR AREA s/SQ.ET.
Fi Licensed Profenional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
F LLZ3S 1 herem byefirm that l aexempt from the Contractor's License Law roe the SPEC ALCRCU T/M SC
po following recon.(Senior,7071.5,Business and Professions Code:Any city or
countywhlch requiresa permlttocoratruct,alter,Improve,demalbh,or repair TEMP.METER OR POLE INST.
aoystruRum paortm Its Issuance,also requlreathe applicantfor such permit to
file a signed statement that he la licensed pursuant to the provbiom of the POWER DEVICES
rh Contredor§Lice.law(Chapter 9(commencing with Sedion 7000)of Divi- SWIMMING POOL ELECTRICO slon 3 ofthe Buslnessand Preferoions Cede)arthat he is exempt there(romand VALUATION
the Wes for the alleged exemption. Any violation of Section 7031S by any
applicant fora permit subjects the applicant to a civil penalty of not mare Hun OUTLE7SSWITCHFSFIXTURES
a five hundred dollars(S50M. NEW RESIDENTIAL ELECTS
7,as owner of the property,or my employees with wages as their sole SQ.FT' STORIES TYPE CONSTRUCTION
C 6compensation,will do the work and the structure b nm Intended or offeredfor
5 ❑ 'sale(See 7044,Buslness and Professions Code:The Contradoes Llcerue law
s� -does not apply to an owner of property who Wilds or lmpmvn thereon,and
who doessuch work himself orthmugh his own employees,provided that such OCC.GROUP R9 UMES
Improvements are not Intended or offered formic.IL however,the W llding er TOTAL: OD
improvement bsold withinoneyearorcompieliomtheowner-builderwgI have
thAprelenofproving that he aid not build or Improve for purpose after.). QTY, PLUMBING PERMIT FEEFLOOp ZpNE ppN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec,7044,Busmen and Profenre bCode:
The Contractor's Llrense,Law does not apply to an owner of property who ALTER-DRAIN TER
Wilds or Improvers thereon,and who contracts for such pGojects with a &VENT-WAff-NN
bacteria)licensedpursuant to the Contractor's License Law. BACK FLOW PROTECT DEVICE FEE SUMMARY
IJ r am exempt under Sec B k P C for this reason
OUTSIDE IT I'S
Owner Dee DRAINS FIAOR RODF,AREA,CONTI. SANITARY Y_ N
WOR"AN COMPENSATION DECLARATION RECEIPT It
❑I hereby affirm that I have a certificate of consent to aelf-Insrre,ce a HRTVRES,PER TRAP SCfiOOLTAK Y_ N
certificateofWorken'Comp timil ranmoracedif4 mpythemof(Sac. RECEIPT If
3800,lab GAS E.A.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
Polity RECEI'r N
Co say GAS-EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
Cunified copy is hereby famished.
C]Certified copy is filed with the city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhissection need not becomplded time permit isforonehundred dollars SEWER-SANrTARY-STORM EA.200FT Date Recei t#
(aIID)oifyth ENERGY FEE Y N_
I certify emptor, any Pattern
manner
so a;too oo pemnit is Issued, WATER HEATER W/VENT/ELECTR
I shall not employ any person In any manner at n to become subject to the
O Worken'Compenvtion laws of California. Data WATER SYSTEM/TREATING PAID
Applicant
Z0 NOTICE bmmrx ibL,ct to
akeens'Comparatr making his ican pro ofonsofthe Labor
NEW RESIDENTIALPfMB._SQFT. Date Recei f#
shoul1"• Code be mus eurthwit the Workers mach pnvisinswthiowrmit s Lab be
WN Code.dr must forthwith comply withsuch proWioru orthb permit shall be TOTAL:
> seemed revmkea. BUILDING 'E
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(flrmthat there b a mmutncilon lendingagency(or the perform ELECTRIC FEE
O ance of the work for which this permit b Issued(Sec.3097,Civ.C.) TOTAL: x
V Lender'sName PLUMBING FEE
IL F Lender's Address QTY. MECHANICAL PERMIT FEE
O Icertilythat l have madshuappTicatiooaod natethatthe above information MECHANICAL FEE
It.WIs earned.I agree to complywlth all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
�. fA relating to Wilding construction,and hereby authnrlae represntatives ofthu,
H Z city to enter upon the abmvcmentioned property for impaction Purposes. ALTERORADDTOMECH.
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,costsand expenses which may many wayaceue AIR HANDLING UNIT(TO 10,000 CFM)
against said City In consequence of the granting a this permit. SUBTOTAL'
AIR HANDLING UNfT(OVER 10,000CFM) CONSTRUCTION TAX
Slgnawre
HAZARDOUS
o(ApplCor MATERIALS DISCLOSURE Dute IXHAIIS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
Will thcappileant or sow building occupant store or handle h=rdous HEATING UNIT CRO 100,000 BTU)
mealth and defined bytM penin Municipal Code,Chapter 9.12,and the Date Recei t#
Ilcalsh and Sally Cod c Ion 2S532(a)7 HEATING UNIT(OVER 100A
❑ YB9 No TOTAL: t.
Will the applicant or fuwre dding occupant-by ordevices VEN37LATION FAN QINGISSUANCE DATE
which emit hararehou air mrntandetlnedbythe Bay Area Air4 lity Mawgemcnt D' o BOILFR-COMP 0HP OR 10Y s No4haverea them a ous materialrequ lremenb derChapter6.95mf BOILER-COMP(OVER 100,0the re foml alshCo ons 2550 "533 and 25534.7
understands t (the ilii not o ave a tenant,that it b my NEW RESIDENTIALMECH1
nsponsibllity yshe sol sh Iements which must be mot a
priortoismance, of0 ''•
Ownermraor BT TggO
e Date - •C
cat `
TOTAL: ISSUEffBIT�1//�-a'✓a'w"`�al
I'f
OFFICE COPY