19625 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address: 19625
38
Phone: p A
IZ,69-32,73 CITY OF CUPERTINO-BUILDING DIVISION
tred res ' `, _Lk.No: APPLICATION / PERMIT b
'31!0-'1).5�` BUILDING-MECTRICALPLUMBINC-MECI NNICAL CATEGORY CONTROLp
Architect/Fsgimer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafOrm that l am licensed under provisions ofChapter9(comment. APPLIANCES-RESIDENTIAL JOBDESCRPIION
Ingweh5etion 7000)oforce at Dl affect ofthe8utneuand ProfessionsCode,and my ���
license Is In tion force and affect PANELS
Llrenx Class LIc.N
Date Contractor
ARCH ITECPS DECLARATION 201-1000 AMP"'
Oce Z I understand my plane shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
❑O
() Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECWLCIRCUIT/MISC
I herebyafBrrnthat l amexempt from the Contractoh License law for the
7.p following reason. 7031.5,Business and Professions Code:Any city or
�Zt.� county which requires a permit to construct after,Improve,demolish,or repair TEMP.METER OR POLE INST.
anystroture prior to its issuance,also requires the appBcant for such permit to
0.V file a signed statement that he Is licensed pursuant 1.the provisions of the ]OWER DEVICES
Contractor's License LawfCha er9(comn�encin with a B`v SWIMMING IDOL ELECTRIC
shoal olthc Business and Professions Code)orthal he V exempt there(romand VALUATION
the basisfor the alleged exemption. Any violation of Seton 7m IS by any OU LETSSWITCHES..FIXTURES
applicant furs permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR
RI,as owner of the property,or my employees with wages as their sole SQ'FT. / SfOlUES TYPE CONSTRUCTION
t�7Q compeasatton,willduthe work and thesuuture is not intendedre
or afferent for
D sale(Sec.7DM,B.,00ass and Professions Code:The Contractors Liceme law
does not apply to an owner of property who Wilds or improves thereon,and
E who doessuch work hlmselforthwgh hisown employees,provided that such C.CROUP RFS.UNITS
improvements am not Intended oroffered foruk.It howevep thebullding w TOTAL:
Improvement issold within one yearof completion,the owner-W Bderwlll have
it Idea of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
nI,as..at of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7044,Business and Professions Code: p�
The Contrstors License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
builds or Improve@ thereon, and who contracts for such pojects with a
cpPII dor(s)Brensed pursuant to the Centimeters License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ 1 am exempt under Sec. B k P C for this masOUTSI DF FEE S
on DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
(Tuner Date RECEITM
WORKMAN COMPENSATION DECLARATION FO(Il1R6S PER TRAP SCIiOOL TAX Y_ N
❑I hereby affirm that I have o lmurne of consentamdifi to pythsam,w a RECEIPT 0
ce0011.aeofWorken Compeneationlneuranre cera tttifled copy themo/0iec. GAS EA.SYSTEM-1 INC.40I1TLET5 (] PARK FEE Y_ N
poli lab C.I —
Poiicy p RECEIPT p
Cam say GAS F.A.SYSfGf-0FA)VER4( BUILDING DIVISION FEES
ffCertmed copy 6 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CerlBied copy Is filed with the city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recel t#
(This section need not W completed lithe permit V for one hundred dollars
($100celess.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I nertity that In the performance of the work forwhich this pem
A is Issued,
I shall not employ any person In any manner so as to herome subject to the WATM SYSTIM/TREATING
Worken'Compewtion Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ef. Dale Rete) t#
Z 0 NOTICETO APPLICANT:If,after makingthla Certifkateof Esempnon,you
should become subject to the Workers'Compensation provlslorsot the Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be
W j deemed revoked. BUI 1 G '
CONSTRUCTION LENDING AGENCY SEISMIC FEE
T hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
a n
Z Leaders Naork(car whkhthb pdrmitbtssued(Sec.3097,C1v.C.I TOTAL' .Dy
V O Lenders Nme PLUMBING FEE If
U. Lender's Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irned. thall agreet complyeread is withal)
and c u ty hatthe ordinances els Rate ion
CL larormt.7agreelo comply with all dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating I.Wilding consuuctlogand Mreby authorize reprexntativ..flhl
F Z city to enterupon the above-mentioned property,for inspection purposes. ALTERORADDTOMECH. Dale ReceI I#
(We)agree to save,Indemnify an d keep harmless the CBy of Cupertino P
V
against cies,judgments,cots and expenses which may in anywayade,nd AIR HANDLING UNIT(TO 10,00 CFM) SUBTOTAL:
aga' d City In mns ce of the granting of this permit.
(/�tl�Wc��+ MR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
r\ Signatumof Appllcant/Contrncty�� Date IXHAUSr FI00D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
liezlth and Sif,ty Code�+.-S�r tion 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
[3 Y. u No
Will the applicant orfuturcbullding occupant use equipment orcievices VFN7ILATION FAN(SINGLE RFSID) ISSWAA&bATE
which emit hazardous air rontardwnts as defined by the Bay Arca Air
Quality Management District? 80ILFR-COMP OHP OR 100,000 BTU) FEB UU 159U
Yns No
have read the hues ous materlalsrcqulrcmentsunder Chapter6.95 of BORER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25534.I .!
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. �
SQ. . City Bt: rIIPpI TIRO
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
Owner orauthorlred agent Date ISSUEDBY:� � U
TOTAL:
OFFICE COPY