19619 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro eat Identification I PERMITNO.
Bulldog Add.. -i
19619
i�
sate: Phone:
nes CITY OF CUPERTINO-BUILDING DIVISION
Contractar'e Name: Lie.Nm APPLICATION / PERMIT -- �---
75 BUILDING-E.ECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL a
ArchltM(FaRleeer. Lk.No:
QT-y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addres!'� PERMITISSUANCE ,Q� ❑ I'�
LICF.NSEDCONTR under rDECLA RATION L.�
with Se alirrinthat 7000)of am DiA.i 3.fthederpravLNonaofeWonsr9(mmmrn APPLIANCESRESIDENEIAL JOB DESCRIPTION
ingwlthSl. 7000)ofd difeon30lthe Buslnmand ProfeWonsCod,and my
license islnluR rce end d(ect. PANELS r
Llcenn Clan Lk.M x�/.._��^
Date _ — — Contractor ` l
ARCHITEC75DECLARATION 201-IMOAMPS
�flzfl
I understand my plans shall be used as public records. OVER1000AMPS EQ.FT.FLOOR AREA f/SQ.FT.
Licensed Professional - SICNSELECTRICAL
6 OWNER-BUILDER DECLARATION
I'n SPECIALCRCUIT/M1SC
L, !hereby affirm nhaticum exempt from the Contractor's Llcenn Law fee the
$o� following mason.(Section 7031.5,Business and Profession.Code:Antl or
�ZI" county which requires a permit to construct,alter,Improve,demolish,or repair TEMP. OR POLE INST.
S�
any structure prim to its imance,also requires the applicant for such permit to POWER DEVICES
PJ
file a signed statement that he b licensed pursuant to the provisions of the
3p� Contractor.Lim Law(Chapter 9(commentlng with Section 7000)of Divi- SWIMMING POOL ELECTRIC ,
< 7.
sion3oflhe Bua ..dP.1fmWnsCode)orthathebexem iherefromand VALUATION the basis for the alleged exemption. Any violation of Section 70315 byany V OUTLETSSWITCHESFIXTURES
.pJ applicantfor.permit subjects the applicant to a civil penalty of not moreZ
W 0ndred dollars C$500).
I,as owner of the property, NEW RESIDENTIAL ELECTR sOFf. STORIES TVPECONSTRLCTION
�n p party,ormy ructum inwithwages r their
compennllKaBusdoth.workandthes Code:
is not Intended orofferedfor
Osale(Sec IiaµBusiness and Ikofedbns Code:The Contractor'.License Law
$ don not apply to an owner of property who builds or improves thercon,and inOCC.GROUP RES.UNITS
who don suchworkhlmselforthmngh hismenemployen,provided that such
Improvemenbammo tendedorofferedfornale.ILhmw r,the WlMingor AL: zc .QQ
Improvement bsold within onsyearofcomplmbN the owner-bu0derw111 have
llgjkudeno(provingtht he did not build or improve fmpurpme.f.le.). QTY, PLVADKGP FEE
u1,as owner of the property,am excluslvsly mnlracting with I—.— FLOOD TONE APN
contnctore to construct the project(See 7074,Bu.Men and Profmbns Code: PIRO I ANC I
-Ob
The Contmnoes License Lew don not apply to an owner of property who A -DRAIN&VV-WATER(EN
Wild.or Improves thereon, and who moment for such p(ojects With a FEE SUMMARY
cgp(pctm(s)licensed pursuant to the ContnRor's License Law. IXPLOW PR T.D E
I em exempt under Sec. B&P C for this resson
DRAINS R SANITARY Y N
Owner Date .RECEIPT a
WORKMAN COMPENSATION DECLARATION
SC OOLTAX Y N
❑1 hereby arf n that 1 have• lmurcertificate of consent to pythn ure,w te ' 0 RECEIPT'a
3800,Laeo(WOrken'Compemwtlanlnuranm me certlfkd mpythereof(Sec. GAS EA.SYS1#4 INC4 OUTLETS PARK FEE Y N
1'Wlry p GAS EA.SYSTEM-OVER 4(FA) DING DI M
' Com any BUILDING DIVISION FEES
F difind copy I.hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
GDf'jwWed copy is filed with the city Inspection division.
CERTIFICATE OF E(EMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 200FT Date Recef lM
(Thlsamlion need not be completed If the permit Is(atone hundred dollars
(Sloo)orlm•) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that in the perfannunce ofthe work forwhich this pennon Is Issued,
I shag not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Wmken'CompensaHon Laws.(California.Date PAID
-
z Z NOTICApplicaE NEW RESIDENTIAL ELMS._SQIrT. Date Recel IN
O NOTICE TO APPLICANT.If,after making this Certificate o(Exem)rtlon,you
should become subject to the Workers'Compensation provisions of rise Labor TOTAL:
7q Cod,you at forthwith comply with such provision Or this permit shall be N
G FEE
W 7 dmmed revoked. BUI
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there is a construction lending agency for the perform / ELECTRIC FEE _ O
Z ance ofthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: 6, 0
V O Lander'.Name PLUMBING FEE , D
LL ~• LendeYSAddmse QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irenl/ythat l have readthbepplirnionand statethattheabove Information
1 Iscornect.lagreetocomplywithaBcityandcounlyordlnanrnsandrtatelaws PERMIT ISSUANCE A .OQ FEES PAID
} N : relating to building construction,and hereby authorbm represent.tivesofthb
I.— Z G city to enter upon the above-mentioned property for inspection purposes. AL1'ERORADDTOMECH. Date R2CC1 7M
V (We)agree to save,indemnify an d keep handled the City of Cu pertlno
against liabilidjudgments,mesa and expenses which may In anyway accrue AIR HANDLING UNIT Q010,000 CFM) SUBTOTAL:
agabstsaid Cityin ones n sof a granting of this permit.
O AIR HANDLING UNIT(OVER 10,OW CIM) CONSTRUCTION TAX
Signature of Applicant/Connie rDate — EXHAUST HOOD(W/DUCT) X-0 CONSTRUCTION TAX PAID:
HAZARD(WS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle haaardous HEATING UNIT(TO 100,000 BM Date ReceI tit
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
health and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
qYn M NO
III the a pplim set or/uture build Ing Occupant use equipment or devices VENTILATION FAN(SINGLE RESIT) ISSIImNRC47111 TE
Which emit havamdou.air conte mlwn nes defined by the Bay Area Air Y-PSl1�'-
Qu ality,Me rugement District? BOILER-COMP DHP OR 100,0010 BTU) II��
4Yea ❑❑No V j 1990
havc read the haciddous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTII) FEB
the California Health&Safety Code,Section 25505,75533 and 75534.1
understand that if the building does not currently have a tenant that it b my NEW RESIDENTIAL MECH. EQI.7.
responsibility to notify the Occupant Of the requirements which must be met City of Cupertino
priortomuanceo feat o(Oavpancy.
a 1
Owne cur out oris agly Date ISSUED BY.J. I/L✓
TOTAL:
OFFICE COPY