19682 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
building Pro+ect Identification PERMIT NO.
Building Address:
vy9K dow-e7 Ale 19682
rs ante: Phone p
,f, !�• W4A) L/Z K I �b CITY OF CUPERTINO-BUILDING DIVISIONAm
G.nt r Lk.No: APPLICATION 1 PERMIT 3
10 e M U'7 BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Arch teci/Engineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERIMITINFO
Add.. PERMITISSUANCE - ❑ E:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby
ecflonAffirm that DiAsiam en3oftheuMmmandpo Chapter9(rommn APPL[ANCESRESIDENTTAL JOB DESCRI'1TON
IngwlthSecdon7W0)of DlWalan3o(the Buslreea+andProleuionsCode,and e
Ifmnse ie In cad effect. PANELS
Limn Ch® Lich /)p'Jp
UP TO 200 AM
ARCHITECTS DECLARATION 201-1000 AMPS
mO Zp Iundenland my plaruehall be used As public recordw . OVER 1000 AMT'S 'SQ.FT.FLOOR AREA f I$/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SI'ECIALCIRCUfT/
7 E'�� Ihercbya(firm thatlam exemptfromthe Contractor's License law(or the
p following reason.(SMion 7031.5,Bunlnen and Profenl...Code:'Any city or
FZI.e TTMP,METER OR PO ST. 0A W
� �` counlywhlch requlrma perrtdttocorutmet,alter,improve,demollshorrepalr
q < anystructme prhRto its lsuance,also requlrestheapplicant forsuch permit to POWER DEVICES
U Ole a signed wtemeol that he is Rcenaed pursuant to the provisions of the
Q6 3 w Cnnlnct ea License law(Chapter 9(commencing with Section 7000)of Divi- SVkMNG POOL VALUATION
O Akm3 ofthe Buu
slnnsand ProfentmCode)mthat he lsesem lherefmmand S
f' G the basis for the alleged exemption. Any vlolatlon of Section 7011.5 by any O 'ISSWITCFiFS
Applicant fora permit subjects the applicantto a civil penalty of not cones than N V
R five hundred dollars(SM. NEW FNTIAL TR
sQTT. STORIES TYPEe STRUCnoN'
I,as owner l the property,or my employees with wage as their sole
E,7Q coo it willdothework,and thesroctureh norIntended or License
Law
^� ❑ sale(Sec. pply to an owner of propeProxfsolonrty
who builds
CImproves person Law
d.esnot applytornownelofproughhisonemorlmproovidethnand OCC.GROUP RES.UNITS
who does such
ntsworkNmse intef on nded
hleowne.If,ho evertheed that gigot
ImpmvementsAre not Intended earofc pleio If,h mer-buflderiklingoe TOTAL:
improvementatuld wlthlnoneyearo(completion,lheowner-bu0derwlllluve '
t rdenof provingthat he did not build.,Improve f.rpurposeofsale.). QTY. PVIMBING PERMIT FEE FLOOD ZONE APN
Ll I,as owner of the property,am exclusively contracting with licensed PERM1137799DANCE -
rontncton to construct the project(Sec.7044,Business ami I'mfmalc m Cade:
The Contractor's License Taw don not apply to an owner of property who ALTER-DRAIN&VENT--WATER ffN
Wilds or fmprovn thereon,and who contra for such pt.jects with a FEE SUMMARY
co 14) pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I_J 1 am exempt under Sec B&P C for this reawn
DRAINS FLOOR RECEI'f X
OUTS1 no
ROOF,AREA,GOND. SANITARY Y— N
Owner Date =.
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a mrtlBcate of consent to self-moanFIXTURES PER TRAP Sp{OOL FAX Y N,or RECEU'T N
mrtiflnteofWorkqers'Cqomper/Jtim�1lruuranmoramrt^ifWmpythereof(Sec. GAS F.A.SYSTEM-1 NC.40UTLE15 PARK FEE Y N
RECEIPT
Cm anV lOR� a81.�Ma9.[� CAS EA.SYSI'FM-0VFRd(EA) BUILDING DIVISION FEES
oECertlfled ropy 1.
❑Certlfled copy with thherebytthe de ty city Inspection division.- CREASE/NDUSTRL WASTE INTERCEPTOR ' PLANCHECKFEE -
_
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SANTrARY.SORM EA.200FT. '
(TMs section need not be completed if the permit is for one hundred dollars Date RCtfl I#
($100)or lees.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N
I cerlmfythat N mit the performance of the work forwhich this perIs timed,
I shall not employ any person in any manner m as to become subject to theWATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
e
0 Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date RLroI#
Z O NOTICE TO APPLICANT.If,after nuking t his Certificate of Exemption,you
should become subject t.the Workrse 'C°mpemsatlon provisions of the Labor TOTAL:
LO Code,you at forthwith comply with such provisions or that perodt shall be BUILDING 0p
W > deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffl thatthereisa mrehuction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z anon of the workfor which this permit at Issued(Sec.3097,Civ.C.)
U O Lender.Name PLUMBING FEE
LLY= Leader.Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
ImRffythatl have read this application and statethatthe above information
0 W
1 iscorrect.Iagreet°complywlth all eityand countyonlinancesand nate laws PERMIT ISSUANCE FEES PAID:
>. N relating tobulkhagmrutruction,and herebyauth.rlae represen/ativesofthL9
I.- Z city to enter upon the above-mentioned property for inspection purpose. ALTER OR ADDTO MECH. Date ReCel t#
V — (We)agree to save,Indemnify an d keep harmless the City of Cupertino
against liabilities,pdgments,costa and expenses which maylnanywaya a AIR HANDLING UNIT Q010,0D0 CFM) - SUBTOTAL:
agal dCity in con uquei M ntin o(I 1.permit.
AIR HANDLING UNIT(OVER I0,DXCFM) CONSTRUCTION TAX
51
gWdmof Applicant/Conor or Dat EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARD S MATERIALS DISCLOSURE
Willtheapplcaotorfu re building occupant store or handle hazardous HEATING UNIT(M ID),000 BTU) Date Recel t#
miterlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 2S532(a)? HEATING UNIT(OVER 100,000 BTI) TOTAL: Z rt
❑Yes
nt No U0y
Will the applies,
pplicaor lure building occupant use Nulpment ordevicos VENTILATION FAN(SINGLE RESID) ISJ A dDATE
which emit hazardous air contaminants as defined by the Bay Area Air rM M
Q+a Illy Management District? BOILER-COMP UHP OR 100,000 BTU)
I I ex 9aueomateriabnquirements under Chat pter6.95°f BOILER-COMP(OVER 100,000 BTU) MAR 081990
ve mad the hazy
the Callfomla Health&Safety Code,Sections 25505,25533 and 25534. 1
4 understand that if the building doe.not currently have a tenant,that it is my NEW RESDEMTAL MECH. SQ.FT.
onFausibllity,to notify the compact°f the requirements which=at met ��E Af�qn--4iBn
rm Issuance da Cart of pa t---
e D '/f 1
eermauthoriz<dage to ISSUEDBY._.��6 v`uC`1
TOTAL:
` OFFICE COPY
I