19792 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY dr
Buil ding AddreBuildin -Prooect Identification t
zz893,L I 6 6 PERhITN19792�
Phone:
arse CITY OF CUPERTINO-BUILDING DIVISION
°ntratote Lie No: APPLICATION / PERMIT C
/ BUILDINGELFiCTRICALPLUMBINGMECHAMCAL CA7,E-C'.OAY CON7ROLM
rchltect/Engineer.. . Lk.No:,.
QTY"- 'ELECTRIC PERMIT FEE 'BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE ❑ ❑ t
LICENSED CONTRACTOR'S DECLARATION -
Iherebyaffirmthatlamlcrosedunderprovlalonsof Chapter9(m...' APPLiANCESRESIDEN[IAL JOB DESCRIPTION
'.
Ingwlth5ect1on70f10)ofD(Wsion3ofthe Buslnessand Pro(euionsCode,and my:•
license is lnfuB(prct And feM. a6 2 - P"N°s.. _ !J
License Claw
L.f.7
Dare Contrator
3 ARCHITECT'S DECLARATI 287-1000 AMPS - -
aZ Iunderstandm lata els0 be usedu bBe records; OVER 1000 AMPS . $/SQ.pp.
OCO YP W, SQ.FT.FLOOR AREA
(� Licensed P,&..I..l - SIGNSELECTRICAL
Z. LL7y OWNER-BUIL)ER-DECLARATION
�4 1 hereby a(fimthat l am exempt from the Contractor's License Law for the S[+p,CIpLCR2CU[T/MISC
O$ in
recon.(Section 7011.5,Busineas and Professions Code:Any city or - r
KMcoontywhkhrequ4 iper ttocora[rust,alter,d P,6v,de=lbh,orrepalr TEMP.METER OR POLE MST.
ystmtureprlwtoltslrsuame,alsomquimatheappb=tforsuchpermitto
POWERDEVICES
DEVICES
a signed statement that he is licensed pursuant to the providers of the
3 w0 Contractor's License law(Chapter 9,(commencing with Section 7000)of the SWAIMING POOL ELECTRIC
eion3 of the Businessmd ProteaeiomCode)arthat hebexemptthere(romand tVALUATION
< the basis for the alleged.exemption.-Any violation of Section 7(31.5 OUTLETSSN7TCHESFIXNRFS by any
O aPpUdmt fora permit subjesthe applicant to a civil penalty of not erathan f'n '
live hundred dollars($500). NEW RESIDENTIAL ELECTRJ
[]!,.a owner of the property,or my employees with wage as their sole —SQXT. SPIRITS TYPE CONSTRUCTION
compensation,wBldothe work and thestruture 6not Intended or offered for
O sale(Sec.7044,Business and Professions Code:The Centretoe.License Law
� does not apply to an owner of property who builds or improves thereon,and
who does wchwork himself or through hisown employed,provided that such +OCC.GROUP RES UNITS.'
Improvements are not intended oroffered formic I(,howeveythebuildingor TOTAL: '
Improvement issold within one yearof completiory the owner-builderwlll have
tliLIrrden of proving that he did net build or Improve for purpose of sale.). Qty, .PLUMBING PERMIT FEE glppp 7pF1E '_TPN
LJ L as owner of the property,am exclusively contrating with licensed _ PERMIT ISSUANCE
caatradem cor
to strut the project(Sec 7044,Business and Professions Code: -
The Contratorb License Law does not apply to an owner of property who '
builds or Improves thereon, and who contracts for such ptojets with a ALTER-DRAIN&VENT-WATER(EA)
7BI(ador(s)Ilmnsed pursuant to the Contractor's License Law. FEE SUMMARY
5I am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
Owner Date . . DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT j7
• QI hemSy affirm that I,have a certificate of consent to self-Insure,or a FDCTUIRES-PER TRAP SCFIOOL TAX Y N
mdifkateofWorkeWC°mpemMlonitsuranmoramrtlBedmpythereo((Sec. - - RECEIPT
38Wpoil, ab C.) Cs ey ? 7 GAS EA.SYSTEM.]INCA OUTLETS PARK FEE' Y N_
Po11ry p G RECEIPT If
Co�mppany - GAS EA.SYSTEM-0VER4(EA) - BUILDING DIVISION FEES
Certlned ropy I.filed
the city GREASE/INDUSCRL WASTE INTERCEPTOR PLANCHECKFEE
CertlRed ropy V Ned with the sty Inspecdon
division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID_.
COMPENSATION INSURANCE SEWEA SANITARY STORI.i FA.200FT. Date Recei t#
(Thlssedion need not be completed lithe permit isforone hundred dollars
($100)orlENERGYFEE Y N
- Icerti(ythythatiothe performance of the work forwhkh[hls parcel[is lsaued, WATER HEATER W/VENT/ELECTR —
I shall not employ any person In any manner so as to become aubjet to the NATER BY
O Workers'Compensation Laws of California.Date PAID
Applicant
Z 0NOTICE TOAPPLICANT:H,after making this Certificate of Exemption,you NEN'RESIDENTIAL PLMB. SQFI. Date Re i t#
.� should become subject to the Workers-Compensation provisions of the Labor TOTAL: '
WI Code,you must fort hwith comply with such provisions or this permit shall be 0
y' deemed revoked. - BUILDING E YL
CL CONSTRUCTION LENDING AGENCY - SEISMIC FEE
M Z Ihereby afRrmthat there is a mmtredion lending agency forthe perform- ELECTRIC FEE
and of the work for which this permit is Issued(Sec.3097,Cls.C.) 'TOTAL: '
(,) O Lenders Name - PLUMBING FEE
LL H Lendersfyth tIs QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I.rmod.I dgrent compl withalicetlandcotatethrdinar sand fomiaeon
6 isrorrect.]agreeto complywlth alldtyand rounty ordlnmceeand state laws PERMIT ISSUANCE FEES PAID:
N relating to building mnstmtlon,and hereby authorlu representativd of this -
Z city to eaterupon the above-mentioned property for Inspection purposes. ALTERORADOTOMECH.
— (We)agree to save,Indemnify an d keep harmieas the City of Cupertino Date„ Recei tit
against liabilities,judgments,cnstsand expenses which may In anywayaccrue - AIR HANDLING UNIT(TO 10,ODO CFM)- - SUBTOTAL'
ago [sold Clconsequence oJ`� oftNe p It '
�b//lIJJ hhfQ{ � 91-rp
L a AIRHANDLING UNIT(OVER 10,000 GFaD - CONSTRUCTION TAX
Sig lure of Applicant/Contractor 1, - ,Date FXHAusTHooD(W/DICT)'. CONSTRUCTION TAX PAID:
..HAZARDOUS MATERIALS DISCLOSURE - -
Willtheapplicantorfuture bulldingoavpantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) - „ Date R3Cei t# .
material d defined by the Cupertino Municipal Code,Chapter 9.12,and the
HeaRhznd Safety Cade Sedloa25532(a)7 HEATING UNIT 100,000 BTU) ' 'TOTAL
M Yes ri No . Ii
-Will the applicant or future building occupant use equipment or devdcea VENTILATION FAN(SINGLE RESID) I$$Q TE
which emit hazardous air rontaminantsas defined bythe Bay Area Air t,' -
Qu Iity Management District? BOILER-COMP OHP OR 100,000 BTU)..' ��� 990
.: ❑Ves ❑No'.
Ihaveread the bazardousmaterlab requirements under Chapter 6.95 of BOILER-COMP(OVER IOO,OW BTU)
the California Health&Safety Code,Sedlom 75505,25533 and 25534.1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MEIN. SQ.FI. pr� run .
onsd W �lbI fly to notify the occupant of the requirements which must be an ;
i rto isruan ,a Certificate 0(Occupancy.
er w authorimd agent '-Date I s
TOTAL: ISSUED BY: VV at
OFFICE COPY