19765APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
—Building Project ldrnll(katlon
Budd Ing Add rens:
0 9ND lid �A�IDcE
PFTthI7 NO.
., 1 9765
wnara erre: Phone: -
A
,'
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT
/ "'- C
' 6,
Cono-aRor'a Na :
aryr�j.�//�I I
L fflcc' NN
BNLDING-ELECTRICAT PLUMBING -MMC MCAL
CATEGORY CONTROL#
Architect/Engineer: Llc. No:
ELECTRICPERMIT 'FEE
` BUILDING PERMIT INFO.a-,
. aryl
Address: s SAN//Ict&APERMITISSUANCE
❑ ❑ ❑ � y�
I_d
LICENSED CONTRACTOR'S DECLARATION
Iborebyaffirmthatlamumnsad urdcrprwiu,m..(Ch.pw,9(cx..
APPLIANCES.RESIDEMIAL
JOB DESCRIPTION
PANELS
ingwlth Sm1don7000)of Divslon3 afthe Buslnessane Pro(eselanarede,and my
effect n"�,^
Li...slntuBforcg,;pd
Clsss LV Cont LeAaI rte,,`
Date
Date r]�N ew Contractor MGI AIW—W
-
1e/1�1.
7�/Y jypARCHITECPS DECLARATION
99
I understand my plsm etufi be used ss public records
OVERI0AMI'S
OVER 1000 AMPS
SQ. FT. FLOOR AREA
5/SQ. Ff.
SIGNS ELECTRICA
Licensed Professional
SPECIALCIRCUIT/ -
OWNER -BUILDER DECLARATION
herebyaffirrethatlemexempt from the Contractors L"s lAv` fo e
fogo greeson.�ection 7m15, Business and Professions Code: An tyor
county IchrequirmapertNthocou uct, alt cr,Impmve,derrol ,ormpaIr
TEMP'MEfIX RPOL
anystru riestolts Wuance,alao equl eathe.ppl ante ch pe mtto
file a signed torrent that he ls licensed pursuant tot vialona a( the
POWERDEVIC
SWUTMINGPOOL CTRIC
Contracto/s Lic Lxw(Chapter9(rommenctngwit fon700Wof Divl-
sion3ofthe Busto and ProfeubruGode),utha exempttherefromand
VALUATION
the basis for the site exemption. Any viol n of Section 7m15 by any
appBcentfeusp, is atheipplicanl advilperultyofecternethan
OUTLETSSWITC FIM
five hundred dollen (W
MI,.. owner otthepro ,o employees with wages as their sole
RESIDENT! #LEC SQ.FT.
STORIES
TYPECONSIRUCTION
compenaatlon.. wllldothework thestmeturc V not Intended or offered for
sale (Sce. 7044, Business and 2 ra Code: TheConiractoe@ Licerue Law
dannectapplytoan ofpmpe whabullds crlmprovesthervan,and
whodoessuchwmk Iorthrough own employees, provided that such
OCC GROUT'
RES. UNITS
ireprovementsare t Intended oroffered le. ILhawweglhebuiWingor
T
improvement d withi.... rarofcompl themmer-bullderwill have
ing�urden pmving that he did not build orlm .far purpose oleate.).
u owner of the property, am exclusively trading with Ilcemed
on dors to construct the project (Sm. 7044, Business Professions Code;
QTY, PL BING ER IT" FEE
FLOOD TANS
APN
PERMIT LAVANCE
tIs tnttor'e License Law does not apply to an, own of property who
Wilds or Improve thereon, and who contra for so G jets with a
e¢U(actor(s) licensed pursuant to the Contractors License Law.FEE,SUMMARY
LJ I am exempt under Sec B & P C for mason
ALTER-DRAIN&VENT-WA
BACK FLOW PROTECT. DEVICE
DRNNS FLOOR, ROOF, ARPA, GOND.
FIXTURES PFR •IAAF
SANITARY Y N
RECEIPT p
Owns Date -
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a?anlfirste of consent to self -Insure, ora
cenifimteo(Workers'Comppemattton�irou/r]nm ora certltkdropythereof(Sec.
3
Paltry \I �P1�L` i'V/Ull
ey )/3 /9psfy},ry lj �a /,p1
SCHOOL TAX Y N
R1:CEIxI' X
GAS F.A. SYSTEM -1 INC.40U77.ET5
PARK FEE - y N
RECEB'I'p
CETrr#DIVISION
CAS F.A.SYSTEM-OVER4(G) -
Com y
m
BUILDING FEES
rt fled copy ht hereby furnished.
nl/ied ropy it filed with the city trspectlon division.
GREASE/INDUSR4L WASTE INTERCEPTOR
PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
CREASETRAP
SEWER -SANITARY -STORM EA. 200FT.
COMPENSATION INSURANCE
(Thtasectlonn complaed if the permit bfor one hundred dollen
Date Recei t#
WATER HFATERw/VENT/ELECTR
ENERGY FEE Y N
'
($IM)orleu')' -I
I renifythat In the performance oft o�(or which this permit is issued,
WATER SYSTEM/TREATING
I shall not employ any person In any manner m ei mme subject to the
Worken'Compe... it.. Laws of California. Date
`
PAID
'
Applicant
catepro ofExemption,L you
NOTICE TO ..bj a tote .her making Compehis nsation
Work en' p Lobar
mmesubFwith rmit
Date Revel t#
NEW RESIDENTIAL PLMB. SQ.Fr.
-TOTAL:
,
Code,shoulo
such prwtbn
orchis pevisions
Code,you most forthwith bwith comply with such provlslarsorlhla permit shall
co s
deemed revoked.
B 'E
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
T hereby alfireneha there is a construction lending agency for the perform-
an he work(or which this perMtls iasued ISec. 3097,Civ. CJ
Lender's -
- TOTAL;
ELECTRIC FEE
-
PLUMBING FEE
Lender's Address
Icertilytbatlh.w=dth p itlonand statethat the above information
agree
Is correct. Ito complywltb all rountyordinaIt and etatelawa
QrY. .MECHANICAL PERMIT-`.'•'`- '`..FEE .
MECHANICAL FEE
. f7
PERMIT ISSUANCE �ZO
relatingtebullding rorstmctlon, end hereby. ercpressmail csof thiscity toenlerupon the above-rr loned property for l ton purposes.
(We) agree io save, Indecord an d keep harMeas the Ity of Cupertino
liabilities,judgments, coasand expenses which may in anywayancroo
agai oldCity Insect enceo/the anting of this permit. �� ^�2,�AIR
ALTER OR ADD TO MECH.
;r2EA;D-
Receipt#against
AIR HANDLING UNIT(TO 10,0W CFM)SUBTOTAL:
HANDLING UNIT(OVER 10,OWCFM)
CTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UMU) UNIT 100,000 BT
Will the applicant arfuture bulldingompant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1Z and the
Date Receipt#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
0
.❑alt Yaend Safety Code000 25532(a)7
VENTILATION FAN( SINGLE RFSID)
I$$Ut1Ngj&TE
Will the applica est or future building occupant use equipment or If evince
which emit haeardous air contaminants as de@ud by the Bay Area Air
Qua lity Management Datri
[] Yes o
_-I havereadthehaca ous materials requirements under Chapter 6.95 of
j<C'+' LUJJ
199Uthe
BOILER -COMP Ot I'OR IOO,IXq BTU)
BOILER -COMP (OVER 100,W0 BTU)
California Health Code, Sections 25505,25533 and 25534, I
JUL
al L 1
NEW RESIDENTIAL MECH. SIFT.
understand that i(the building time not mrrcnlly haveatonant, that ltlsnty
responsibility to notify the occupant of the requirements which roust be met
prtorto uannc`ofa Certificate of Occv an
Of CBBf.RhIIP
City 4
ISSUED BY: �a 6K1/
Ow Tor auihori agent Dart,O
TOTAL,
OFFICE COPY