19594 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES = USE BALL POINT PEN ONLY
Building PrWeet Identification - PERMIT NO.
.Building Addre..: .. _ - 19594
O�mai
° Qr�eName
iw PhoneA -
� r2 - ,
co ha era Name: ^ y�y�y�� L No: APPLICATION / PERMIT
BMLDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY- CONTROLN
Architect/Engineer, Lic.No:
it'•1Bt ,UILDING!PERW INFOfj ..'.,It'
. (j'ci'yt1 t t4,ELECTRICLP6RMIT �,}, ,1+�#FEE-a� 4tt,L
Address: PERh9TISSUANCE - ❑ ❑ ❑
1 hereby
aLICENSED CONTRACTOR'S DECLARATION
ffirm that l am licensed under provisions of Chapter9(commenc- - APPLIANCESRESIDENITAL' - 1 JOB DESCRIPTION
ugwfth Secf,m70m)of DwIston3 of,t(heeuWssiinessssannddProfesadonsCode,and my . .
license is In full( d(ect �AF� .. PANELS
LImn�Lic r 1 ] ,
Date Contractor ' 1✓' � '
ARCHITECTS DECLARATION 201-1000 AMPS "
q�q�uu 9 ZO I understand my plans shall be used as public record.. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FC.
Lirensed Professional, SIGNSELECTRICAL, ,
OWNER-BIBLDER DECLARATION - SPFGIALCTRCUIT/MIST
p., Thereby affirenthatI am exemptfromthe Contractor's License Law for the -
Z countywhlch requires.perndtrocona[roti,alter, demolish,or o- following reason.(Section 7031.5,Business and Professions Code:Any city or
r�, M - -
O Z t, TEMP.METER OR POLE INST. -
;�
g nystm=mpeortoitatswance,al mquims Neapplicantforsuchpermittu POWER DEVICES
F file a signed statement that he is licensed pursuant to the provisions of the
Q6 Contractor'.License Uw(Chapter g(commencing with Section 70W)of Dlvf SWW.MING POOL ELECTRI - VALUATION
�0 sion3 ofthe Business and Preftemons Code)crthatt he b exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIXTURES
.yo applicantfora permit subjetsthe applicant to a civil penalty of net more than `
as Q five hundred dollars(S500). STOIIfS TYIPE CONSTRUCTION
NEW RESIDEN77AL ELECIR
..�n ❑I,ae owner of the property,or my employees with wages as ffei sol _
OcomPZ1!. Zwsl Bothework andthestructurebnor Intended orofferedfor _
doe(es not apply
owner
Professions Code The Contractors License Law
who does
apply tornowner ofpropertyrough who
nemoyees,povided themes,that such
- - '
whodoessuch work himself orthrough his ownemployees,provided thatwch - OCC—GROUP RFS.UNITS y ,-
• -
improvereentsamnotfntendedoroffered forsale.ILhowevegthebuildinger
ImprovementbwldwithinomyearofcomplMiogtheowner WBderwBtha e -
nMo.of proving that he did not build or improve for purpose ofslu QTY.',^'a},t?,•PLUMBING PERMIT' `' t'
,as owner of the Property,am exclusively contracting with licensed n ,. t.' FLOODZANE APN
contractors to construct the pm)ect(Sec.7044,Business and Profession.Code: PERMIT ISSUANCE .
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) '
Wilds or Improves thereon, and who contract-for such Ick jects with a -
co,R�actor(e)licensed pursuant to theContractor's Lfcense Law. - �'j, <x tk,$t3+FEE;SUMMARY..
`LI I am exempt under Sec. B&P C for this reason
BAIX FLAW PROTECT.DEVICE" '" "' •'-
Owner Date DRAINS FLOOR,ROOF,ARCA,(bND. :, SANITARY Y N_
WORKMAN RECEIPT
COMPENSATION DECLARATION -
hereby affirm that I have a cartlf cute of consent to self-insure,ora FMTURFS-I'ER TRAP i i. .•HOOL TAX Y_,N^_ ,.
cdd(IcateofiVorkers Com ationlnauranceoracertiftedmpythereof(Sec. - RETE
3800,Lab C.) .y �,/Qe��r� GAS EA.SYFCEM-11NCAOUMMETS ARKFEE Y N
Policy R -I =+.�' 1:/ s2.�.r _ RECEIPT p
GAS EA.SYSTEM-OVER 4(EA)
Com env � r � a - - BUILDING DIVISION FEES
ff5a>-yt ropy is herehy furnished: P GREASE/INDUST RL WASTE INi'ERCEPTOR PLANCHECK FEE
•i�ertified copy is filed with the city inspection division.
GREASETRAP 1
CERTIFICATEMPE SATION N FROM WORKERS' r - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA200FCS ,Date Recei t#
' (fhb section need nothcmmpleted?(the permit bforona hundred dollars . . - _ '
(SIM)or lesi.) ENERGYFEE Y N
Icertify that I.the performance ofthework fmwhlch this permit is lowed, WATERHGTER W/VENC/ELGCTR
I shall not employ any person In any manner an
"am
become wb)ect to the WAFER SYSTEM/TREATING
Workers'Compensation Laws of Lllfomfa.Date PAID
'Z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. ',Date Remi t# '
O NOTICEco APPLICANT: after makingpensation this prviscate of Exemption,of the
Labor -
N should become subject to the Workers'Compensation provisiora ofthe Labor - TOTAL:.
(/3
Code,you=at forthwith comply with such provisions or this permit shall be .. BUILDING
W j deemed revoked. " -
d CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a roretwctfon lending agency for the perform ELECTRIC FEE- `
M Z ... fthe work for which this permit is Issued(Soc.3097,CIv.C),, TOTAL
O O Lender.Name -. PLUMBING FEE
U. F Lenders Address Q Y.. } } MECHANICALrP812MIT` } _ .+' ,FEE"i, MECHANICAL FEE
O W Imdifylhatlhavereadthisapplicationandstztethattheaboveinfor rim L
IL correct.Iagreeta complywithall cilyand rountyordinances and nate laws PERMIT ISSUANCE d � . FEES PAID:
} W relating tobulldingconstructlon,and hereby authorize representatives ofthis
Z city to enter upon the above-mentioned properly for inspection purposes. ALTERORADDTOMECH. Daft Rt#
_ (We)agree to save,indemnify an d keep harmless the City of Cupertino - eCel P
against liabilities,judgments,cost. dexpenses which may In anywayaccrue AIR HANDLING UNIT(TO ldMOCFM) SUBTOTAL:
aggln. ssa�f City iryconpsryencyg�t^he grenting ofthis permit f
',I //, - aa,ey/ ,/�/,ry;{,( /� AIR HANDLING UNIT(OVER 10,000CFMi CONSTRUCTION TAX
Slgnatureof/off Apppplica(vt`//Co(ntrachctorr // rf 1Da It EXHAUSTHOOD(W/DUCD CONSTRUCTION TAX PAID:,
HAZARDOUS MATERIALS DISCLOSURE -
Willtheapplicantorfutore building occupant store or handle hazardousI }IFA77NG UNIT(TO 1m,m0 B7V) �� 'Date ReCeif I#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Coder.�Section 25532(a)? - HEATING UNIT(OVER 100,0m BTU) TOTAL' s
I]Yes u No
Will the applicant or future budding occupant use equiprtsato devices VENTILATION FAN(SINGLE RESID) ISSUANCE.DATE
which endth d us afrmntaMnants as defined by the Bay Area Air
Go.I ty Management District? BOILER-COMP QH POR 100,Om BTU) y� i
Yes t(��No
❑ f/pf
- ?have read the bazaRus materials requirements under Cha pter695 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sect ions 25505,25533 and 25534 I
uddcosts od that lfthe building does not currently have a tenant,that it bmy NEW RESIDENTIAL METH. FQ.I7. �l�a f�
responsibility to notify t
he occupant of the requirements which must be met - a / . .
prior to imuance of a Certificate of Occupancy. S iW
Owner or authorized agent DateI Ll UED BY` V—AC+�1-1-�'e_�T ..
TOTAL:
4 OFFICE COPY,