19799 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'e(1 Identification 7 PERhilT NO.
Bafidh�eli o s t 19799
nen aces. . ^ �.,If7 CITY OF CUPERTINO-BUILDING DIVISION A
Contract rp : ,f Is? "h o. APPLICATION /PERMIT
I 'F BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY COYIAOLX
Architect/Enginrer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ' PERMITISSUANCE ❑ 1:1 C1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provisions o(Chapter 9(rommenc- APPLIANCES-RESIDENTIAL JOB DFSCRE'TION
Ingwlth Scdton7000)of Divblon3 fthe Buslnessand ProfessionsCode,andmy
license lsl fill r rad effect � PANELS
License Cl Lk.# `�
Date_ _ a Contra or Y �^
RCHITECTS DECLARATION v 201-1000 AMPS
w7 Ion ratan myplamshallbeuxdaspublierecords. OVER1000AMP5 SQ.FT.FLOOR AREA 5/SQ.FT.
ct ZOC
U Licensed Professional SIGNS ELECTRICAL
C W OWNER-BUILDER DECLARATION
In Fa SPECLILCIRCUIT/MLSC
t., lamexempt B from the Contractor'sLlanse Law fort he
�O_� followingichregires a permittocostruc andr,imprbv Code:Anydtyor TEh1EMEfEIt ORIOLE INST.
OZI"'u9 county whir.requlrtsapertNttomrotrutt,alter,improve,demolbh,orrepalr
F`'1 any structure prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
C file a signed statement that he ls licensed pursuant to the provlatoru of the
0µ, Contractors License Law(Chapter 9(commencing with Settlors 7000)of Dlvl- SWIMMING POOL ELECTRIC
30�' aem3 of the Buslnessand Profeniow Code)orthat he is exempt therefromand ATION
�Eil Sn the basis for the alleged exemption. Any violation of Stolon 7001.5 by any S OUTLETSSWITCHEs.FI%TUREs
¢n appllcantfor a parent subjects the applicant to a civil penalty of not marc than
a., five hundred dollars($500). NEW RESIDENTIAL ELECTR
$' 1,as awmr of the employees with wages as their sole �'�' STOAI iYl'E CONSTI2I1C7ION
.. property,or my amp ay g
7a
compensation,Boldothe work,Prof- the imu;Codureh isnot Intended or icensedfor
�❑ sale(Sec.9004.Bus.ss...d PmL^ssiom Code:The Coniractota License Law
does not apply to an owner ofproperty who Wilds or improves themoq and �UIa RFS.UNITS
whodeassuchwork himself ortheaugh hlsownemployces,provided that such C
Improvements arc not Intended oroffered for sale.Ifluwever,thebuildingor TOTAL:
Improvement bsold within oneyearofcompletion,theowner-bulWerw111 have
t rdenof provingthat he did not build orimprove for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD LANE AI'N
LJ L as owner of the property,am exclusively contracting with licensed
co
coa
contractors to construct the pmje (Sec.9016,Business and Professore Code: PFAMITISSUANCE
The Contnctals License Law does nor apply to an owner of property who ALTER-DRAIN h VENT-WATER(EA)
Wilds or Improves therece,and who contracts forsuch pAolecb with a FEE SUMMARY
<gWourRor
s)ficensed pursuant to the Contract 's License Law. BAIX FLOW PROTECT.DEVICE OUTSIDEFEES
LJ I am exempt under Sec B k P C for this reason
DRAINS.FLDOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT#
WOR
COMPENISAT ON
• ced�teo Waffirm C�I have a cents ante of consent DECLARATION FIXTURES-
FIXTURES PER TRAP SD•lOOL TA% RF-CEBTN
Flo T y A GASEA.SYS SYSTEM-1OUTLETS — PARK V N
38MPolh La0 CJ et71..Vp RLCEE'Tp
Policy#_ GAS EA.SYSTEM-OVER 4(EA) BUILDING DIV]SION FF.CS
Co any
Slf,rtified copy 0 hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
IpJSCekiBed copy on filed with the city inspection division.
CERTIFICATE OF UMPHON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFRSANITARY-STORM EA.200FT. Date RCCCI t#
(fhlssectlon need nest becompleted B the permit h foroM hundred dollars
(SIMmIcea.) WATER HEATER W/VFM/ELECTR ENERGY PEE Y_ N_
I certifythat in the performance of the work for which this permit is extent,
I shall not employ any person In any manner so as to become abject to the WATER SYSTEM/TREATING PAID
Worken'Compensation Laws of California. Date
OZ Applicant NEW RES DENT AL PLMB. SQFT. Date Re021 t#
Z Q NOTICETOAPPLICANT:If,after makingthb Certificateof Exemption,you
F-
should become subject to the Workar:Compeesatian provisioreof the Labor TOTAL:
UI Code,you must forthwith comply with such provisions or this permit shall be BUILDING I"E
W j deemed rcvoksd.CONSTRUCFION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there isamnstructlon lending agency for the perform- TOTAL: ELECTRIC FEE �j'L
Z ancc of the work for which this permit is Issued(Sec.3097,Cls.C.) PLUMBING PL•E
U O Lenders Name
F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW I mdifythat l have read thisapplicationand statethat theabove Information
1 is correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. misting to building mrutructirn,and hereleyauthorbereprewntativesofthls
F N city to enter upon the above,mentioned property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,todemNly an d keep harmless,the City of Cupertino Date Receipt#
1..1 against liabilities,judgments,emnsand expenses which may In anywayaccrue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit' AICONSTRUCTION TAX
A HA I1NTT(OVER t0,W0 CFM)
Signature of Applicant/Contractor Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllmrt or future building occupant store or handle hazardous HEATINGUNIT(TO 100,00011117) Date Recei t#
material as defined by she Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cod loon255320)? HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Yes ��ttj�-NI
Will the applicant r ro building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCEIDAF
mi
which cent harardous air contanantsas defined by the Bay Area Air
Quality
• Quality Management District? BOILER-COMP DIIP OR 100,000 BTU)
C?Yes No
h.vc read the h..Q us materials requ imments under Cha pter 6.95 of B0TLER-COMP(OVER 100,000 BTU)
the California Health 6 Safety Code,Section 25505,25533 and 25530.I
u rade tandthatifthe buildingfd 's not currently have a tenant,that It ls my NEW RESIDENTIAL MECIILsQ.FT.
r to net the accvsof there ircments soh{ch must met Cltt] o} ctl PTtiP
p ua re. a diff parry. , ��`S�� �y na
n authokud agent ( to s: ISSUED BY:`a"'tom
TOTAL
OFFICE COPY