19470 r APPLICANT TO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
" Ruildln Pm'ed identification -
t0ufiding�ilddna: PERMIT NO, •'
/� Zoo k-eNzi� S,- X30 -0102, x. . 19470
�7 oars arc: _ rhil� CITY OF CUPERTINO�BUILDINGDIVISION
1A .
Co.lrac9or.N.— LIc.N.: 'APPLICATION /PERMIT
1I BUILDINGELECiMIC PLUMBINGMECHAMCAL CATEGORY CONTROL X Slay
Anhltect/Englneer. - LIe.No:
i QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO -
Addreu
PLRMITISSUANCE ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affRm that l am licensed under provision..(Chapter 9(commene APPLIANCES-RFSIDENTIAL BDESCRIPTIO
Ingwith Sect)on70L0)of0iNsion3.flhe Business and PrefessionsCode,and my --/X—
ucense 1.1.fun force and died. PANELS
Licence Clan Cont Iw-Q�
��
Date C.ntndor
ARCHITECTS DECLARATION 2014000AMPS
pre2 I understand my plana shallbs used as public records.' OVER IOW AMPS SQ.FT.E OOR AREA $/SQ.FT.
0++ O
to od B Licensed Professional SIGNS E TRICA
�< OWNER-BUILDER DECLARATION - SPECIAL /
k., Iherehyaffrm that l am exempt from the Contractor's Licenselawforthe -
70 � followln ma .(Sedlon7O3IS,Buslnmand Pr.lmions Code:An d or
O'Z I.� g y ty 7F1dIa.M POLE INST.F� county whlrh requimsa pemdttomrutsud,.iter,lmplove,demolbb,.rrepalr
4 Q anystrudure pdorto its issuance,also requlreslheappllnnt forsuch permit to POWER VCES
U file a signed statement that he Is licensed pursuant to the provisions of the
3u, Contractor'sLicense Law(Chapter 9(commencing with Section 7DOO)ot Divi•
afon3ofthe BusinmmdPMmimCode)ornhathebemmplthemfmmand SWBIIMING POOL ELECTRIC VALUATIO
g
the basis for the alleged exemption. Any violation of Section 7031.5 by anyOUTLETSSWITCHFSFIXTURFS / Q O t
applicant fora permit subjects the apphcant to a civil penalty of not more than
/f a edred dollars(AQ. _�• gT0[Epg TYPECONSTRUCTION
�n I'
a owner,o!the property,or my employees with wages thele sole
NEW RESIDENTIAL ELECTR FI.
nsat044,wW Bothe work,andthe structure b not Intended or License
for
(See.7064,Buelneas and Professions Code The Contractors Llrense Law '
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS '
0. whodoessuchworkhimselfe through hbownemployea,provided that such
urs mvemenbare not Intended oroffered forsale.ILhoweverthebuildingor TOTAL: ,
bnpmvementas ldwlthlnoneyvarofcompldion,the.wner-bufderw0lhave
O%,Zurden of proving that he didnot build orlmprove for purpose ofaale.). QTY, PLUMBING PERMIT FEE }70013 ZONE ApN
11 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7064,Business and Profcaloru Code:
The Contractors License law does nes apply to an owner of properly who ALTER-DRAIN&VENT-WATER(EA)
WOds or Improves there who con tw such Pto)ects with • FEE SUMMARY
q¢lT licensed Pu ant oche Contractors License Law. BACK FLOW PROTECT,DEVICE
cuI exempt we B &P C for this reason
_
DRAINS FTOOIL ROOF,AREA,ODND. SANITARY Y_ N
Owner T Date BBCEB'IX
WORKM COM ENSA ION DECLARATION
❑I hereby affirm that I have a certiftnte of consent to self-Inxure,or s FIXTURES PER TRAP SCHOOL TAX Y N
certificate of Workenmns
'CopeatlonInsurance gracedlfled ropy thereof CS". RECEPTN
38 W,Lb C.) GAS EA.SYSTEM-1 INC4 OUTLETS PARKFEE Y N
PoIIry X GAS.EA.SYSTEM.OVER 4(EA) RECEIPT p
Com any� BUILDINGDIVISIONFEES-
Cerliliedmpybherebytumlehed. GREASE/w13USIRL WASTE INTERCEPTOR PLANCHECKFEE
CeeRied mpy b flied with the city inspection division. ,
CERTIFICATE OFU MPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIN OINSURANCE
(Thissection need nob be ao SATE tithe permit ls(.none hundred dollen SEWER-SANITARY-STORM EA 200FT Date Rawl PtH
($100)mless.). WATER HEATER w/VFNT/ELECTR ENERGY FEE Y N
I certify that In the pertornance of the work for which this permit is Issued, —
I shall nes employ any person in any manner so as to become wbpd to the WATER SYSTEM/TR MING
Workers Compensation Lawson Cailfomia.Date ' PAID _
.z NO7licant
7CETO APPLICANT:It,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FE. Date Recd tN
should become,subject to the Worken'Compemation provisions of the Labor TOTAL:
F Code,you moat forthwith comply with such mwblons or this permit shall be s U
W j deemerevoked: PY - P BUILDING PEE _
CONSTRUCTION LENDING AGENCY SEISMIC FEE r S�
a Iherebyeflirmthatlhereb a coatrudlon lendingagency for the perlornv
0
TOTAL: ELECTRIC FEE 0 anceolthework for which this perMtlsburred(Sec.W97,CIv.C.)
LL Lr.dre,Adde - PLUMBING PEE
LL U Izn mdiAaarea QTY. MECHANICAL PERMIT FEE tim MECHANICAL FEE
O W Icedify tagreet comply
with aBatyndcounty ordinances and mate
aam
6 lsco:nd.building complywo,all ndtyandauhorier repressandmsofthis PERMIT ISSUANCE FEES PAID:
} (n city to gtobulponte abowr.Mandhereby dpropauthorizerectionpurpss.this
(_ Z tltyWenter
ee to the above ne,nlWrud propertyforinspection purposes. ALTER OR ADDTO METH.
_ .(We)agree to ave,1 crrW n d keep hermim the City of Cupertino Date ReceiplN
st llabilitlds,pdg in cost dexpenmuwhlch ymyaceme AIRHANDHNG UMT(TO10,WBCEM) SUBTOTAL: Z9. SV
a I abald Clt In con uance he gr.nlingo penult.
AIR HANDLING UNIT(OVER Io,Boo CEM) CONSTRUCTION TAX
SI ature of Applicant/Contractor Date LXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZAR DOGS MATER IALS DISCLOSURE
Will the applIa nt or future bund Ing occupant store or hand Is hazardous HEATING UNIT(TO I W,ODO BTU) Date RCtei IN
mmerbl as defined by the Cupertino Municipal Code,Chapter 9.17,and the ,mss^
.Health end Safety Code Section 25537(e)? HEATING UNIT(OVER 100,000 BTU) - TOTAL: J
Yes No
WWtheapplicant or/uturebulldingoccupantuseequipment ordevim VENTILATION FAN(SINGLE RFSID) ISSUP��TE
which emit hazardous air contaminantsa.defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,0W BTU)
• ❑Yes n No
Ihavc read the h.12us materials expleements under Cha pier 6.95 of BOILER40MP(OVER 1 W,000 BTU) IAN O� 7p(�il
j
theave Hcelth&Safety Code,Sect ions 75505,25533 and 25534.1 _ dFt IJ ,V.
undenland that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.ET.
responsibility to net ify the occupa nt of the requirements which swat be met +
prior to issuarace of a Certificate of Occupancy. -City of rimertipa
Owner or authorized agent Date 1 ISSUEDBY:�• V`T0'A�i
TOTAL: `\
OFFICE COPY. . `I