19736 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES J USE BALL POINT PEN ONLY
Building Pooled Identification PEtMITN'O.
*T,Z>1 5 L1, 1 . 19736.
Phone: A AA IL
iLl—N
Owner's 1)Name
`, CITY OF CUPERTINO-BUILDING DIVISION
nrtractorsslanrcAPPLICATION /PERMIT Z l Q 6
C— Et.No: BUILDING-ELECTWCALPLUMBiNG-MECHANICAL CATEGORY CONTROL#
Architect/Engineer Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: / q5az PERh9TISSUANCE I Zt�
LICENSED CONTRACTOR'S DECLARATION
flumbyaffirm that[am licensed under provisions of Chapter 9(onmmenc APPLIANCES-RESIDENTIAL OB DESCRIPTION
Ingwith Section 7000)of Divisicn3 ofthe Businessand ProfessionsCode,and my
license is in full force and effect. L� PANELS
License la Lk.p
Date Conor or—
ARCHITECT'S DECLARATION 2011000AMPSOVER1000AMP5 SQ.FI.FLOOR AREA $/eS .Fr.
qqWW uNOu�O I understand my pias shall be used as public records.
EU�j Licensed Professional SIGNS ELECTRICAL
¢¢L
Qto OWNERBUILDER DECLARATION
m SPECIAL CIRCII[T/MISC
L., (hereby afRrm that lam exempt from the Contractor's License Law for the
7 Q.,., following reason. ER
(Section 7031.5,Business and Professions Code:Any city or TEMP METOR POLE INST.
OLf'u9 countywhichrequlresapermitmcomtmRalterimprove,demolbh,orrepair
�E4Cea anystructure priorto its Issuance,alsorequires theapplicant for such permitto
file a signed rttemN
aent that he Ikensed pursuant to the provision of the ('OWER DEVICES
Ow
Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- VALUATION
In SWIMMING POOL ELECTRIC
30 sion3 ofthe Businessand Proferelora Code)orthat he Et exempt there(romand
< the basb far the alleged exemption. Any violation of Section 7ML5 by any OUTLETSSMTCHFSEXTURFS
applicant(ora permit subjects the applicant to a civil penalty of not morethan
w o five hundred delta.65f)(3). NEW RESIDENTIAL ELECTRFr.
❑1,as owner of the property,or my employees with wages as their sole c"Q' STORIES TYPE CON57RUCR'ION
cumpenaation,willdo the work anithestructure is not Intended or offered for
psale(Sec.70K Business and professional Code:The Contractors License Law
$� does not apply to an owner a property who Wilds or improves thereon,and OCC.CROUP RES.UNITS
who doessuch work himself or through his own employees,provided that such
improvements are not intended oroffered forsale.If,however thebuilding or aCV 2
improvementusoldwithinoneyearo(complelon,theowner-builderwll+M1ave r,J
t"rden of proving that he did not build or improve for purpose of sale.). QT'y, PLUMBING PERM FEE FLOP ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUA E
contractors to construct the project(Sec.7004,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN - ffNN
Wilds or Improves thereon,and who contracts for such pSo)ede with a FEE SUMMARY
cq➢![+ctor(s)licensed pursuant to the Contractor's License Law. BACK FIAWIPRO T. EVICE
LJ I am exempt under Sec. B k P C for this reason
OUTSIDE FEES
Owner Date DRAT SFTAO ;,ASO COND. SANITARY Y N_
RECEIPT#
WORKMAN AN
DECLARATION FIX TRAP SCHOOLTAX Y_ N_
❑YheK
mby affirm that I have a certificate of consent to self-insure,ora RECEIPT It
certificate o(Workers Compensation insurance ora certified copythereed(Sec. G -1I O S PARKFEE Y N
3900,lab C.)
RECEIPT If
Policy# G S .Sy A 4(EM BUILDING DIVISION FEES
Com any
ertif+ed copyk hereby furnished. GR SE/IN LWA FP'rOR PLANCHECK FEE
Certified copy V(ikd with the city lrepecalon division.
CERTIFICATE OF Et(EMPHON FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEWER- MTARY .200Fr. Date Recei [#
ffhissection need not be completed If the perml[k forom hundred dollars
($100)or less.) WATER HEATER W/VENT/ELFCTR ENERGYFEE Y_ N—
I certify that In the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject lathe WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z Z NOIICETOMPLICANT:7Laflernuk+ngthts Cedtfiateof Exemption,you lican NEW RFS7DLNTIAL PLMB. SQFr. Dale RCCeI t#
O should become subject tothe Workers Comperaatlon provislorao(ahe Labor TOTAL:
CC N Code,you most forthwith comply with such provisioru or this permit shall be BUILDING FEE
W omaeeedrevnkea.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there is a construction lending agency 097for the perform- ELECTRIC FEE Q�
M Z onceof the work for which this permit is Issued(Set.3 ,Civ.C I TOTAL:
qZ
00
Lenders Name PLUMBING FEE
IL I- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImrtifythatIhavemadthisapphotionand statethattheabove Information
correct.is I agree to comply with all city and county ordinances and sesta laws PERMITISSUANCE FEES PAID:
>. IL elating tobuliding construction,and herebyauthorberepresentativesofthls
(— U) chyle enter upon the above-mentioned propertyfor inspection purposes. ALTFRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Dale Rece)p[#
V against liabilltks,judgments,costs and expenses which may in anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City fn consequence of the granting of this permit. AICONSTRUCTION TAX
R HA l0,Q70 CFM(
Signature of Appucant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reaei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ma�yy,,
Ileahh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: f 4b
❑Yes M No
Willthe applicant or future building occupant use equipment or devices VEYDIATION FAN(SINGLE RESID) ISSU�NC„ F�J{1TE
which emit hazardous air contaminants as defined by the Bay Area Air
slity Management District? BOILER-COMP OH OR 10,000 BTU)
FfL'
Yes .-�IJ1 No
have read the huarTous Pmaterials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU) ('t� zl 1990
the California Health&Safety Code,Seaiola 05,25533 and 75534. 1
understand that if the bu fid d oftar lyhave a tenant,that it is my NEW REST DENTIAL MECH. SQ.FT.
responsibility to n then ofthe ircrrcnls which most be mety�
prior to I an f rtific a ecu
Ow autM1orlud ag t Dat
TOTAL: ISSUED
OFFICE COPY