19665 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Idenufir tion - PFX.wTNO.
Building Address:
V73 Lo 6 GG/ASU .19665
Phone AI'I'Ll�AIIUySUbMIIIjAL )All
7 ',ZA ,& AIWAaL"OT2 CITY OF CUPERTINO-BUILDINGDIVISION
Cana ora Name: �p Lie.No: APPLICATION I PERMIT
BUILDING-ELECTRICAI.PLUMBING-MECIIAMCAL CATEGORY CONTROL It
Architect/Engtneee Lic.No:
QTY ELECTRICPERMFT FEE BUILDING PERMIT INFO
Address: El 1:1 1:1LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE
]hereby affirm that under provisionsofpr9c- AIfLIANCESRESIDENTIAL JOB DFSCHON
Ingwlth Section70W)of Uivtsion3ofthe8usnesandProfessmsCode,and
my
license is in r� deflect. PANELS GSM
Licen k �L Uc M_�� - —7
Date Contractor ' � 201-1000 AMPS
ARCHITECTS DECLARATION
o4 Z I understand my plain stall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O
a �j Licensed Professional
SIGNS ELECTRICAL - -
L
<�m OWNER-BNLDEft DECLARATION all
SPECLILCIRCU(T/MISC
L, 7 Iherebyaf(irm that l am exempt the Contractor's License Law for the
0 Z Y Q following reason.(Section 7031.5,Business and Professions Code:My city or TEM#METER OR POLE INSr. -
u1 cwntywhich requlrcea pertNt to corotruct,alter,Impmve,demoiuh,orrepalr
P anystruchm,prior to its Issuance,also requiresthe applicant lorsuch permit to POWER DEVICES
Vfile a signed statement that he b licensed pursuant to the provinors of theIs
3 q Com.d.es License Law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING]VOL ELECTRIC
sum3 ofthe Business and PmenslomCede)orthat he is exempttherefromand VALUATION
5 the has.for the alleged exemption. My Wolatlon of Sectbn 70315 by any OUTLETSSWITCHESHXTURES Odo
-
app8nnt fare permit subjects the applicant to a civil penalty of not more than a
F, es five hundred dollars(5500).
I,as owner of the ro NEW RESIDENTIAL.ELECTR SQA. STOIUES TYPE CONSTRUCTION
7 G ❑ p perty,or my employees with wages as their sok
compensation,will do the work and the structure Is not intended or offered for
D sale(Sec.7044,Business and Profeasiow Code:The Contractors License law
F$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RIS.UNITS
doessuch workhimselforthrough hisownemployees,providedthat such
improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
improvementissoid within aneycarolcompiniogtheowner-W 8derwill have
the¢aroan of proving that he aid net Wild or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
L1 L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sec.7044,Business and Professions Code: PERMITISSUANCE -
The Contractor's License law does not apply to an owner of property who ALTER-DRAW k VENT-WATER(EA)
Wilds or Improves thereon, and who contractsfor such pVrm with a
on FEE SUMMARY
,,00.t.{.&m(s)foamed purouant to the Contractor's License Law. eAIX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
OUTSI DE FE'S
DRAINS FLOOR,ROOF,AREA,CONE). SANITARY Y_ #N_�
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FIX.IURES PFR.fRAP SCHOOL TAX Y_ N_
❑1 hereby a(Rrm that 1 have a certificate of consent m seB-loare,or RECEIPT#
certificate of Wm]us.'Compersation Insurance or a certified copy thereof CSec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38W' RECENT#
Poll,# G ,- �0 7 + GAS EA.SYSTIM-OVER 4(EM
Com any rpael_ d>M BUILDING DIVISION FRES
�Certified< yls hereby furnished. GREASE/WDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy b(fled with the city Ikpactlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID .
COMPENSATION INSURANCE SEWER-SANRARY-STORM E.A.200FT. - Date RCCCI IH
(rhtssection need nu be completed if the parmot b forora hundred dollars
(slot mrolWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I oertlly yth N wMat the performance of thewk for which this permit is]wad,
I shall not em I jny person In any manner,an as to become subject to the WATER SYSTEM/TREATING
workers
'map
o rx uaa laws at California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date Recef t>I
Z O NOTICE TO LITANY:IL actsr nukmgthis Certlflote o(Exemption,you
should bee Tr
IC_totheWorken'Compensatlon provkiorsofthe Labor TOTAL:
Coda you must forthwith comply with such provlslow mthis permit shall be
W
> deemed revoked. BUIL 1E -(7'O
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyatfirm thattherebacom[ruction kndingagencyfortheperform- TOTAL: ELECTRIC F
OEE
M Z ance of the work for which this permit is issued(Sec.3097,Civ.C.)
L) lenders Name PLUMBING FEE
LL t- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certlfyth t l have read thsapplication and statethatthe above Information
C iscorred.I agreeto complywithalletyand countyondinances.e dstate law. PERMIT ISSUANCE FEES PAID:
W relating to building constroction,and hereby authmfze representatives of this
U) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date ReCei t#,
(We)agree to save,Indemnify an d keep harmlesa the City of Cupertino P
V against liabilities,judgments,rosta an xpensea wNch may In anywayacwe AIR HANDUNC UMT(LO 10,000 CFM) SUBTOTAL'
agai Cit: ag ofthijEarmit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sig of AppBant/Contractor Data EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAlARDOUS ATERIALS DISCLOSURE
Will the applicam ormmreb ilding occupant store or handle hazardous HEATING UNIT OO 100,000BTU) Date ReCei tf4
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I leallh and Safety Code'Se 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 5
❑Yes Na
Will the applicant or rutumbuildmg occupant use equipment or devices VEN"FIATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contartnants as dented by the Bay Area Air
Quality Management DistrictT BOILER-COMP GHPOR 100,000 BTU) �A
4Yes Ira{-nom/o
havcmad the hazartousmaterials requirements under Chapter G95of BOILER-COMP(OVER Its,"BTU) 1-�� �pno
the California Health k Safety Code,Sections 25505,25533 and 255M.I 7.l
understand that if the building does not currently have a tenant,that it a my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the ant of the requirementsp
which must be met
to issuance ole Carti'at fOc Fancy. P
L
er or authorized agent Data ISSUED 8 ({[_
TOTAL
OFFICE COPY.