19857 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Prm'eat Identification PERMITNO.
"*141-2 sFFVrZD A2 19857
nrraName: Phone: A
CITY OF CUPERTINO-BUILDING DIVISION / q D
ontractor's Name: 1� Lie.No: APPLICATION / PERMIT ( —?D
LI<.No: BUILDING-ELECTRICALPLUMBINGCO
MECtIAMCAL CATEGORY NTROL X
Architect/Engiver.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: ' 14RWTISSUANCE � �Q
LICENSED CONTRACTOR'S DECLARATION K
IhOmbyaffirm that lam licensed under provisions of Chapher9(comentere. APPLIANCESRESIDENTIAL JO DESCRIPTION
incense 1.1.IOU to.afd eff act. ofthe Businessand Pro(esslonsCode,and my
license is In IOU(Orae and Vigo. PANELS C(
Ll...ClassLica L
Date Contractor
ARCHITECPS DECLARATION 201-1000 AMPS
0p70 I understand my plans shall W used as public records. OVER 1000 AMPS ': M_ 1A g/�.
W J
x Licensed Professional SIGNS ELECTRICAL ,� !1 ,5PU
/1
<
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLIC i therebyafRrm thatlam exempHromthe COntraator'c Llanx Gwlor the --/7.0-'� I011owing reason.(Section 7031.5,Business and Professions Code:Any city or / 1?
O 7 F. TEMP.METER OR POLE INS(.
Fa county which requiresa permit tomvtructalmr,improve,demoltsh,or repairQAT
�a N anystm=mpr rtoihbaaance,aLwrqutrestheappliantforsuchpermitto pO— DEVICES 1
O`O ilk a signed statement that he b licensed pursuant to the provisions Of the _V D
Mu
� fn ContraRora License Law(Chapter 9(commencing with Section 7000)of Divi-
OS sion30ftheBusinessandProfemiomCode)orthathebexempttherefmmand SWIMMING POOL ELECTRIC VALUATION
Sri the tresis for the alleged exemption. Any violation of Scion 7031.5 by anyD O a d IJ
<5 applicant for a permitsubjects theapplicant to a civil penalty of not more than OUTLEISSWITCHES-FIXTURES D
r. five hundred dollars(SM.
7
F11,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR c•'U�. SID ES TYPE CONSTRUCTION
C 6 compensation,will dothe wor,.Od thestrucure is nor intended or offered for
S ❑ sale(Sec.7044,Business and Professions Cade:The Contractols License Law
does not apply to an owner of property who Wilds or improves thereon,and OCC,
V- who does such work himself orthrough his own employees,provided that such GROUP RFS.AMTS
improvementsare notintended oroffered forsale.ILhoweverthebuilding Or TOTAL: 6,Afl
improvement is sold within ore year ofcompielton,the owner-builderwlll have
Yrden of pnevingthat be,did not Wild orimprove for purpose ofsale.), QTY. PLUMBING PERMIT FEE ROOD ZONE APN
S as Owner of the property,am exclusively contracting with licensed tractors to construct the project(Sec.70K Business and Professions Code: PERMIT I55UgNCE
The Contractor.License Law don net apply to an owner of property who ALTER-DRAIN k VENT-WA
(E/V
Wilds or Improves thereon,and who contracts fee such project,with a
ccfactor(.)licensed pursuant to the Contractor's License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B k P C for this reason
. Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Date RECEIPT N
WORT W I have a S TION DECLARATION
I
herebyorifi hat I have a certl0ate of consent to self-insure,or T�1' SCHOOLTAX Y N
insure,ora K• �� RECEPT'N
certlflateof Workers Compensatlonlnsuranm ora certl(kd copytheraof(Sec, GAS FA SYSIEM-
olicyabCJ tINC.40[IILE75
PQ'D PARKFEE Y_ N_
Polity M GAS EA.SYSCEM-OVER 4(EA) RECEIPT N
Com any BUILDING DIVISION TEES
Certified
copy b herebyth the city
d. GREASRANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Ccrtlird copy b tiled with the city W ptt[ion division.
CERTIFICATE OF E%EMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thlssectioncoodnct Wcampletediftheperont bforonehundreddollars SEWER-SANITARY-STORM EA.2DOFP. Date Recei t#
($]00)Orfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify thatln the person In
tnumner so as to bco permit blto the
1 shall cot employ any person In any manner so u to become subject to the
Workers Compensation Lawn of California.Date WATER SYSTEM/TREATING PAI D
Z NOTICE
OT(AppliE NEW RESIDENTIAL PLMB. SQ}7, Date Recei t#
Z L7 should ETO AI..bjmi M:Q,after ns'CO thisCertificate
pre O(Exemption,
eLyou
should you
mme aubjM to ith co Workers'COmpevason s or this
pof ermit
s labor TOTAL:
WW Code you musHOrthwilh comply with such previsions or thio permit shall be
> dff1""Irevaked. BUILDING •E FS
d CONSTRUCTION LENDING AGENCY I hereby a(Irm that there is.conamctlon lending agency for the perform y/Vsx EE7Z anceoftheworkforwhichthispermitbLawed(Sc,30Y/,C1v.C.) TOTAL: DyU Q I.ender.Name EE LL 1— Lenaer'.Aadre.. QTY. MECHANICAL PERMIT FEEOW I certlfythat l have read this_.ppRotlonand statethttheabove informdion AL FEE
1 bcormet I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE 2..VG N relating to building consWnion,and hereby authorize representatives of thio `'Zcityto W)aree to the above-mentioned Property for Wpolon purposes. ALTER ORADDTOMECH. a ytO\4
(We)agree to.ave,Indemnify an d keep harmless theCtyOfCoprtn0Receipt#
against liabilities,judgments,costs and expenses which may in any wayaceme AIA HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this pemnit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigvtereot Ap�l 3Date / EXHAUST HOOD(W/DUCT) 6. So :CONSTRUCTION
�TAX ID:A,ZARDOUS MATERIALS DISCLOSUREWill the applicant orfuture building occupant stare or handle hazardous HEATING UNIT(TO 100,000 BTUmaterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the ) #
Healthand Safety Codr Section 25532(a)7 t[EATWG UMT(OVER 100,000 BT(p
❑ Ye. M No TOTAL: e3a _11QQ
Will theapplicant orfuture building occepantmeequipment m devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
QuicheManaement iitrict? Mwnbasdented by the Bay Area Air PAIL)
Quality,re Management ha Dis No BOILER-COMPOHPOR 100,0(10 BTU)
Yea II��No
have read the haszrr ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the CalifornialI.Ith ASafety Code,Sections 25505,25533 and 25534.I IHHf( 1 3 1�yU
understand that Ifthe Wilding does not cvrrcntly have atenanL that iib my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to nctify the occopant of the requ Immenls which must be met p
Prior to issuance Of a Certificate of Occupancy. ' ylty(ff CIJP9PfIRR
Owner or authorized agent Date tx
TOTAL: 23 00 ISSUED BY: y— O�4U
OFFICE COPY