19732 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmzed identification PERMIT NO.
Balding Addresa: - /Wh �• %���'a •. 19732
'758/ 130
one:
A
Mamma D)2
04 /3 CITY OF CUPERTINO-BUILDING DIVISION
CO°'r °' 'I'S' R ./. •� i APPLICATION 1 PERMIT ( (/
7(O 1 BU LDINGELECTR CA41 LUMBINGMECHAMCAL CATEGORY CONTROL N
rehlted/Engineer. Lie.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrcsc PERMBTISSUANCE a . ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under previsions ofChapter9(commore, APPOANCESRESIDENTIAL JOB DESCRIPTION
IngwithSecton2000)of Divl,lon 3offlu Bu esesand PrnfeedonsCode,andmy
I Is In fu a d cited. 7/ PANELS
License C1. LIc.N
Oak Contractor LIP TO 200AMPq
ARCHITECTS DECLARATION 201"1000 AMPS 111 �4
�p!90Zp l understand my plans shag be used as public mccrds OVER1000AMPS SQ.FT.FLOOR ARPA f/SQ.Fr.
E�(� Llcenacd Ptofessbrul 9GNS ELECTRICAL
<<I^n 6 Flr'7 OWNER-BUILDER DECLARATION gpECIALCUtCllIT/MLSC
1herebya(firm that sen exempt from the Contractor.License law for the
o following reawn.(SMion 70315,Business and Pro(eesions Code;My d
OZt-� ty or TEMP.METER ORPOLE INSf.
Fy countywhmitich requlmsa pertoconsmct
t ,alter,lmprove,dm
eollsho, rrepair
anystrocturepdartollsKwame,aharequimatheapplimntforsuchper tto POWER DEVICES -
O III ..igned statement that he b Ilrensed pursuant to the provisions of the
Contractor's License Law(Chapter 9 3 (rommendng with Sectkm 7000)of Dtvl-
SWP1hING POOL ELECTRIC
Kon 3 ofthellushossixthe alleged
exemption. Any violation
heh exempt therefrom and VALUATION
the bash for the permit
sexemption. Any ttolatWn of Becton 70115 re any
« fiveapplicantdredapears($S subjects the applicant too civil pemltydnat onrethan 0[TILETSSW[TCFiESEIXTUIRFS
five hundred dollars(SSON. NEWRESIDENTIALELECTR_SOFT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
rompensadon,will do the workk,and the Krocture It not intended or offered for
O sale(See.704q Business,and Professions Code:The Contractor's Lt..law
(?,1 � does not apply to an owner of property who builds or improves thereon and OCC.GROUP RES.UNrfS
0.0. whod..a hworkhl.U.rlhroughhi o..employeegprovidedthatsuch
Improvements are not Intended oroffered forsale.It hmveveg thebuilding or TOTAL:
improvementiewldwlthlnomyearofcompldloNthe owner-builderwlll have
illgLIIttrden of pmving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE MN
LJ[as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contactors to construct the project(See.7044,Business and Professions Code:
The Contractor's Licame Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, sesuch,d who contracts for such, twith a
cgR((echurls)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
ee
LJ I am exempt under SB&P C for this reawn
01]Tq[DE FEES
DRAINS F=R,ROOF,AREA,CONI. SANITARY Y N
Owner Date RECEIPT N
WOR"AN COMP ETISATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
❑1 hereby atflrm that I have•certi(Irate of consent to spythwre,(Sa RECD M
certlflL.bC.Worken'Compensatlonlnsuranceore certl(kd copy thereof(Sec. GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y_ N
39 ry bC.) �a--cvcP-�l�3`l
Policy N pAECEIIrTN
Comm tang �r//-s7/. CAS FA.SYSCEM-0VER4(FA) BUILDING DIVISION FEES
Lf Certified copy is the furnished. GREASE/INDUSIRL WASTE EPTOR PLANCHECK FEE
Cerltied copy t(Tied with the city inspection division.
CERTIFICATE OF EXEMIF'ION FROM WORKER GREASE TRAP PAID
COMPENSATION INSURANCESEWF.ILSANITARY RM EA 200F'I' Date Recei t#
Rhle section need ns,be complded]fila.permit laforone hu oil
(SII me IfY that
WATER HEATER /VENT/ELECM ENERGY FEE Y N
(certify employ
any peoum In an tmunnerhe work for this 1 besotted,the —
I shall not employ any perwn In any manner at u to c jed to the
Workers!Compensation Taws of California. ITR SY.Date /.TREATING PAID
ZZ Applicant RES[ AL PLMB. SQ.Ff. Date Recei t#
Z O NOTICE70 APPLICANT,If,after mal ng thhC I t of Exe pt
H should berome subject to the Workers' cam sa provlslo f aor TOTAL:
fA Coticyoumustforthwlthcomply M au r lomurlh rad ii be
W > deemed revoked. / BUILDING
F3 CONSTRUCr N EN INGACEN''{11{••rT��// SEISMIC FEE
(L I herebyaffirmthat them its a ionlendingagpncyl rt perform ELECTRIC FEE
M Z ance of the work for which this p t Is Issued(Sec.309, 1 .C.) TOTAL:
02 render'.Name I A iW PLUMBING FEE
LL F Lender'.Address V QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U• L'
O W 1certltylhallluveread thlsappllationand state—
0 ve orrrution ��TT
lscened.I agreeto complywith ell tllyand muntyordlnan Katetawa PERMITISSUANCE of FEES PAID:
} 1 relating to building construction,and hereby authodae represe lives ofthis
IA city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMFCH.
? (We)agree to save,Indemnlfy and keep harmless the City of Cupertino Date Recei [#
V agalnstli dBea,judgmenb,coatsendexpensea which may in any ay accrue AIA HANDLING UNIT 8010,000 CFM) SUBTOTAL:
agar t a t Inconsequence of the granting of this permit.
7eD MR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signals fAppliant/Contractor /5Da. EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WlfitheappBant or future building occupant store or handle haaardous HFATINC UNIT(TO 100,000 BTU)
matedalasdefined by the Cupertw Municipal Code,Chapter 9.12,and the Date RCCCI t#
Heahh and Salety Cade Section 25,532(.)2 HFATING UNIT(OVER 100,000 BTU) TOTAL:
n Yea No
ZJIIItheappllcantorr . building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSI'1•&AlCOMATE
which entt haaard...I,coetamlmnbas defined by the Bay Area Air a' .
• Quality Management District? / BOILER-COMP DHI'DR 100,IX0 BTU)
Yes n❑No q
have read the hazarclo. materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BN) .�4'I{`� U sy, IssJ
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does net currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQFT.
responsibility to not ify the p.et of the rquirementa which at be met City of C(p1Qrtina
Prior to Issuance of a Certificate of Oecopancy.
Owner or authorlud agent Date ISSUED BY:J.
TOTAL:
OFFICE COPY