19391 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlfiotion PERMITNO.
Building
d ,10/�3�(iA/. / r 193
91
cae a S Phone: A A A
CITY OF CUPERTINOLBUILDING DIVISION
Centracters Name: Lic.Ne: APPLICATION I PERMIT
�a'/A.$TA.pUCT1�. 5^611771 BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORYC,ti•^//_�
Architect/Engineer. Lic.No: v •(/�--�
f_ . Rt TTC On. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
PERMITISSUANCE ❑ ❑ ❑
LICENSED ONTR under rDECLA RATION
I hereby
Sedco lrmlhatlamlicensed 3o(the ugp Chapter 9 enc A1'1'1]ANCESRESIDENTIAL JOB DESCRIPTION
Inense 11.full 7000)of Dl effect ofthe Buslneseand Pro(esslonsCode,and my l
license is In full force and effect PANELS �
Date Class• Contractor
S6 e(7.� l/ I
Date Contractor
ARCHITECTSDECLARATION OVER00 AMPS
07 (understand my phns shall be asci apubllc records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
COC
a�U Licensed Professional SIGNS ELECTRICAL
Q w OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MLSC
L, 7 Ihercby a(Rrm that am exempt from the Contractor's License law for the
O�F following reason.(5sethm 7031-5,Business and Professions Code:Any city or TIME.MEITR OR POLE INST.
FSS county which requires a permit to construct,alter,Improve,demolbh,or repair
Ym anystructure prlortolts Issuance,alsorequirestheapp]scar for such permit to POWER DEVICES
y. I file s signed statement that he Is licensed pursuant to the provisions of the
Contractors Licees� Law(Chaver9 �
(ro.rein IthSection70M)ofDivi-
�Os aton3o(theBusmeeandProfelowCode)orthaheatexempttherefromand SWIMMING POOL ELE _VALUATION
the basis for the alleged exemption. Any violation of Station 7ML5 by any OUTLE.rsSWITC FI `' /"l�l`
O applicam mien for a pert subjects the applicant to a civil petry of not more tha o O00
c. $ five hundred delta.NSM. NEW ESIDEluTAL LC sQ�T. STORIES TYPE CONSTRUCTION
F1 1,as owner of the property,or my employee with wages as their sole
1-75a6 compensation,willdo the work and thestructure b not intended or offered for
9 F O vie Ike.7'OK Business and Professions Code:The Contractors License Law
� $ does not apply to an owner of property who builds or improve thereon,and
$^ who does suchwork himself or through hisown employees,provided thi ch OCC.GROUP RES.UNITS
Improvements arc not intended or offered for sale.If,however,the building or O
ImprovementissoldwhhinonerarofcomplMtm theowner-bullderwillhave
tffurden ofp—i.g that he did net build or improve for Purpose o(sale.). QTY. P IN RMIT FEE FLOOD ZONE APN
u 4 as owner of the property,am exclusively contracting with licensed P UANC
contractee to construct the project(See.70K Business and Profesns sioCode:
ct '
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)builds or Improves thereon,and who counters for such Imajects with a
mpf(aRoKs)Bonsed pursuant to the Coniine] rs License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_I I am exempt under Sec. B& P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCLICOL TAX Y N_
❑1 hereby affirm that I have a ert1(Icate of consent to self-Insure,ora RECEIPT#
certificate ofWmlxcr'Compensation Insurance ora certifled copy themcf(See. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
380D,Lab C.)
RECEIPT#
Policy p GAS EA.SYSFEM�OVER 6(EA) BUILDING DIVISION FEES
Com any
�Ceri
[:[Certified copy Is herebydwith thehed. GREASE/INDUSTRL WASTE IN'TFRCEPTOR PLANCHECK FEE
❑Certified ropy Is filed with the city Inspection division.
CERTIFICATE OF EX0,4PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OFr. Date Remi t#
(Thlssealon need not be completed if the permit Is for one hundred dollars
($IW)or less.) WATER HEATER W/VFN'f/CLECTR ENERGY FEE Y_ N_
1 umlythat In the performance of the work forwhlch this permit Is Issued,
I shall not employ any person In any manner so as to bene.subject to the WATER SYS1FM/TREATING
WorkrseCompensation Lawsof Callfornla.Date PAID
QZ Applicant NEW
RESIDENTIAL PLMB. SQFT. Date Recei t#
Z NOTICETOAPPLLCANT:IS after makingthb Certificate of Exemption,you
W should become,subject to the Workeri'Compereatlon provisions ofthe Labor TOTAL:
� ;
Cods,you=at forthwith comply with such provisions or that permit shall be BUILDING •• 1.4rO
W — deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Thereby affirm that there Is a construction lending agency for the perform- TOTAL ELECTRIC FEE
• Z anceofthe work forwhichthis permit Is Issued(Sec.3097,CIv.C.)
U O Lender's Name PLUMBING FEE
LL I— Landers Address QTY-i MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1mrify thatl have reacithis applicatlonand statethat theabovelnformation
1 Ncorrect.l agree to comply with all city and county ordinances and state law, PERMIT ISSUANCE FEES PAID:
>. 0. to building cormWction,and hereby authorize representatives oflhis
rN city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.
Z
_ Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V
against liabilities.judgments,cosh and expenses which may In anywayaaxue AIR HANDUNG UNIT(TO 10,000 CFM) SUBTOTAL: 7
°�ga Ira vid City Inco a nm oft grant' !this permit.
-- B AIR HANDUNGUNIT(OVII lO,OWCI) CONSTRUCTION TAX
Sig ature of Apphcar /Contractor # /Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the apidlunt or future building occupant store or handle hacarcims HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
IWith and SafetyC ctlon 7SS32(a)r HEATING UNIT(OVER 100,000 BTU) TOTAL: 7-
❑Ye No
WIIl the applicant o fumrcbuildingaceupantussequipm etordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
whichemitharardous irconta retracts as deft read by the Bay Area Air rjC6tl®
Quality Management Districts BOILFRCOMP DI♦)'DR IOO,IXq BTU) 1L
Yes o
have read the hua wmateriaIs requirements under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Coliforms Health&Safety Code,Secmons25505,25533and2553E.1 1 J Iygo
undcetand<hat ilthe bulltling docs not currently have atewn4 that itIsmy NEW RESIDENTIAL MECH. fQ.FT.
responsibility to notify the occupant of the requireis which at be met
primtoisuanceofe III coroavyancy. City Ot Cnrnrtinq
net or authodnedagent Date TOTAL: ISSUEDBY:Q/Q
OFFICE COPY