19689 r-v aanvw — vvr L9a,_t_ rvm l rLll v14LI
Buildin Project Identification
Building Address: PERMIT NO.
19689
ner• ante: hone
A A A
" CITY OF CUPERTIN6BUILDINC DIVISION J g
" L N APPLICATION / PERMIT 3 l3 ( O
Arehkect/Fsginser ZlostLib 87 TP
CATEGORY CONTROL
Lie.No:
YtiTM,::{,.�
QTY}z„,_>:=;ELECTRIC PERM1T�e�":;" .(FEE: ` "" BUILDING PERMIT INFO
Add..
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby eHtrm that l am licensed under provWonsof Chapter 9(mmmm APPUANCES-RESI13c IAL ]OR DFSCRB'TION
Ingwlth Settbn7000)./Dividm3 ofthe ButlnnsadProleW onsCode,ad my
license b In ! d eff cs �• PANELS
Clot. - Lie N AACHITEA ON " / IDI�OOZ ]unde�standrM pbns,ha84 used as pubbcremnls OVER 1008 AMPS SQ.7in
Licensed Prufional SIGNSELECTRICAL
,< OWNER-BUILDER DECLARATION
I hercbya(firmthatlem..empfromthe C.;Amdm'.LicenseLwfmtheSPECIALCIXCUIT/M
following rcaaon.ISectlon 70315,Businessand Pm(mi°ns Code:My city or
muntywhichrequimapermltwmruml„aw,,lmpm ,demollah,orrcpalr �P.M=ORPOLE
anyst =mPriorwibimance,alsonquimtheappUmtrorsuchperrdttofile,a signed Yatement that he ts licensed pumuantmthepcovbions of thePOORD�Contractov.license Law(Chap.,9(mmnencing with Sctin 7000)of Owl.
a n30ftheBuWmandPMmioaCd.).rthak-bexemptthemfmmand NG POO CVALUATION
the hula for the alleged exemption. Any vidadon o/Section 7(315 by any 5 O Q
__'� applicantfor•permit subjects theappHcanttoa civil penskymnm more than D FH OZONE
ri"mined dolWs(S.M.uI,uowner d the IMPerty,or my employm with wages a the&sole NEWALYPE CONSTRUCTION
mmperaation,willdolhework,andthesMdu ,b rwt intended.,offend for7 P:❑ ale ISM 7611,Bushsarand Pro/mions Code:The ContractorsLlca_don not apply to an owner of pmperty who build,orimprovethereon,ad
whodoessuchw.rkhmortforthrwgh Msovnempluyeea,Provided thatsuch FS.UNITS
Imrovements are rwt Intended or.flered forale.IL however,thebulldingcr TOTAL:
Improvemembsmd withlnoneyear.feempinbRthc owner.,caderwillhavet Adenofprovingthathedidnmbuildorimprove(orpurposeo/ale.). ��'t: +-dC u owner of the property,am suba vey contracting with licensed • ; :PLUMBING PERMiT e' FEE' . PN
oonmttontomnsWct the Project(See7011,Buslnmand Pmlmbns Code: PERMIT ISSUANCE
The Contractors License Law dm nm appy to an owner of property who
Wilds or imp.thereon, and who contacts foe such ptojede with a ALTER-DRAIN&VENT-WATER MA)
qati-d-4)B.wued pursuant to the Contnttora License Law. ARY
SUMM .''
1 am exempt under Sec B k P C for this meson BACK FLOW PROTECT.DEVICE - v"» - - -
rt2a. Owner Date S DRAINFLOOR,ROOF,AREA,CON I. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT N
QI hereby aHbm that 1 ism•certificate of consent to seH- FIXTURES-1'ER TItA1' SCHOOL TAX Y N
Nerre,ora RECEBaI M
mrtNdate o(Worken'Compensatlon Insuracema certified copythemof bee.
3800 di..I" _ CAS EA.SYSTEM-1 PARK FFR Y N
Com N I7:C RECEIPT
y��Z� EA.�EM1�) BUILDING DIVISION FEES
nn
Ce mea copy as mmiNed.
[DCenified copy ts filed with the city Inspection division. /INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' TRAP PAID
COMPENSATION INSURANCE
RNssection need
($100)or Im3 net becompleted Hthepermlt b r0 A -SANITARY-STORM EA.2IXIFT. Date Recei t#
IcenfylhatirLhe Pen.msna.rthework(or h dials ATpi HEATER W/VENT/FT.ECTA ENERGY FEE Y N
I shag nm employ any person In any manner so t
Workers Compensation Laws of California.Dat WATER SYSTEM/TREATING PAID
a Z Appliwt
0 NOTICE TOAPPLICAto,H,after makingthb mnyou NEW RESIDENTIAL PLMB. SO}7, Date Recei t#
N ahmld become subject tt the Worken'ComPe tl An o ha Labor TOTAL:
_ Cale,you Mort Imthwlth mmplywlthmchprovi,ions°rthisperontchalibe
> deemed revoked. BLIIL12ING FEE
DO
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
J2 Ihereby affirm that there b a oamtructlon lending agency for the perform. ELECTRIC FEE
sem of the work for which this permh b issued(see 3097,Civ.C.) TOTAL
FO Lend.e.Add PLUMBINGFEE-
lender.Address t •r'•,, ... .,,.,
LU Icenlfylhatl havercadthb applications nd statethattheabovelnformation MECHANICAL-PERMIT,,y :',!;FEE.”; MECHANICAL FEE
1 bcorrem lagree EE
it'. ordinanm.andtlatelaws PERMITLSSUANCE FEES PAID:
W re.ingtobulldingmnstmttion,and hembyauth.rizempresemativeso/thio -
Z cityi.a.mrupon the abovcmentioned property for ins Ion purpo.er. ALTER OR ADD TO MECH.
(We)agto. iMemN s and keep hamdethe City of Cupertino Date Receipt#
aree gaWtlbbWtba,jrd9 nus,cots and e.pensea wss hichneymarywayaceme AIR HANDLING UNIT(TO 10,00)CFM)
.gat dCitybmn ems egr ting m apemdI. SUBTOTAL:
AIR HANDLING UNfT(OVER IB,BDOCFM) CONSTRUCTION TAX
Si Mmof Applicant Contract to F7(F1AO57HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOU MATERIALS DISCLOSURE
WIIl the applicant.r future ulldingoccu nt stomor handle hazardous IiFADKC UNIT(TO tOD,WO BTU)
material as defirud by the Cupertino Municipal Cod,Chapter9.12andthe Date RCcel t#
Health Ya allh and SafetyC°deiBet]jprfL5537(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
o
Will the applicant AT/uhma building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$SLLAQI�DATE
which emit haeard.us air consNants a deli and by the Bay Arca Air
mef�'1�((�u
Quality Me agent District? BOILER-COMP OHP OR I W,000 BTU)
4Y. LK
uvead the eath&SafetyCodnabreons255nbundeaC 25534. 91 of BO LER-COMP(OVQ 100,D00 BTU) Mµk 1 3 1990
the Californiab Health A Safety Code,Sections 25501,ZSI3 and 25537. 1
understand that if the building does nm mnently have a tenant,that it is my NEWRESIDFNTIALMECH. SQFT
Act IbBity to notify the oc al°fthertquvementawhichmustbemel
P rt iauanceofla nifi t o/ rcup.qw. p�iN rF r!I^ortlllll
net or aut onzedagen Date
70TAL: ISSUED BY.' �I/IIIG�
OFFICE COPY