19678 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES' USE BALL POINT PEN ONLY
Building Project lde rification PERMIT NO.
Building Address: (YY7&�"Ozzz Jay,�vao 19678
OwnergName phone: APMICA nON SUBMi I I A
Ta J [! 1 , CITY OF CUPERTINO-BUILDING DIVISION Q
cont or'e me: LIc. UINo, APPLICATION /PERMIT
r ;!!Ltc BLDINGELECTRICAI PLUMBING-MECHANICAL CATEGORY CONTROLM
ArcbRect/Engineer.. ` Lle.No:
QTY ELECTRICPERMIT FEE ' BUILDING PERMIT INFO
Address:, PERM)TISSUANCE - El O ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter 9(commdc APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIng with Section 7000)of Division 3 ofthe Business and ProfessionsGode,and my '
licenseis In fu defect. O PONTIS
LicenseGla LIcX
Dat Cormxcto /q,�.f C.fi��77N
ARCHITECTS DECLARATION 701-IODDAMPS (/� /1r
poi all 2o l understand my plans shag be uad m public records OVER 1000 AMPS SQ.FT.FLOOR ARFA $/SQ.PT.
E U Licensed Professional WNER•BUILUER DECLARATION SICNSELECTRICAL
G OSPECIAL CIRCUIT/M19C
F, Thereby afBmnthat I am exempt fromthe Contrsctoes License Law for the
ZOfollowing reason.(Section 70315,Business and Professions Code:My city or
pg 6 cougtywhi,h requires a permit to cmutma,alter,Improve,demolish,orrepair TEMP'METER OR POI^ ST.
a any atmcturc statement
Wuae is LLwrequ pursuant
rovixfhpermlt a POWER DEVICES
106 u�V Ole a signed statement that he V licensed pursuant to the provialoru of the ,
i.,� Coomaaore License Law(Chapter9(commencingwith Section 7000)of Divi- SWB.4MI POOL EL C
�0� slon3oftheBuslnensandProfessbnsCode)orthathebexempttherefromand VALUATIONQa
yd the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects rooms the applicant to a civil penalty of nere than OU1LE HJCIl1R
ai Bvo hundred dollars(5500).
�n ❑I,as owner oftheproperty, NEWR AL ELECTR STORIES TYPE CONSTRUCTION
ul my employees with weed as there sole
C mmpensatlon,wWdothe work andthc structure is not intended or offered for V
does am '
9 O sale(Sec.7ply to ainowandf property Code:The Wilds or improves
mpLidrue Law
whodo.applytoanownerofpropgh hisonemporlmproovided that such
OCC.GROUP RES.UNITS
Improwments am not mxUorthrwgh hiaowne.If,ho ever,tdedthatsu or
improvenent i are not Intended proffered for lila.If,howevegiheerlldingve TOTAL:
improvementbeoldwithin oneycarofcomplaloMiheowner-W IMerwlllhave
thiLburden of proving that he did not build or Improve for purpose ofule.). QTY, PLUMBING PERMIT FEE
Lf I,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to constmet the project(Sec.7044,Business and Pro(edbv Code: PERMIT ISSUANCE
The Contractor's Llcerue Law does not apply to an owner of property who ALTER-DRAIN&VENT•WATER(EN
Wilds or Improves thereon, and who contracts for such ploje. with a FEE SUMMARY
aAt(+ctor(O licensed pursuant to the Contractors License Law. BA WI'ROTFCT.DEVICE
LJ I am exempt under Sec B&P C for this reason
OUTSIDEFEES
Owner - - Data R,ROOF,AREA,COND. SANITARY Y_ N_
RFCERT N
0
1 hereWORKMAN COMPENSATION DECLARATION
by.flbm that I have a certificate of consent to sel6lnsure,or a S tER TRAP SCHOOLTAX Y NRECEBT M
artl(IcateciWorkers'Compensation Insurance ora certifled copythereof(Tec GA STEM-1INC4OUTLETS PARK FEE Y N
3800,LabC RECEIPT
C. '•' G STEM.OVER4(EA)
Com any BUILDING DIVISION FEES
[Certified y 6 hereby furnished. NDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
F1 Certified copy is filed with the city Inspection divisl
kEksg
CERTIFICATE OF EXEMPTION FROM WO .ids PAID
COMPENSATION INSURANCE -SANTfpRY SIDRM EA 200FT Date Recd I#
(This section need not be completed litherm
permit Is for h
($100)or lex) WATER HEATQt W/VENT/ELECTR - ENERGY FEE Y N
I certify that In the performance ofthe work forwhlc' hlspemdtbiawed,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
worker:Compenestbn Laws of Callfomia.Date PAID
O Z Applicant NEWRE5IDENTIALPLMB. SQFL Date ReceT t#
Z O NOTICE TO APPLICANT.If,after nuking this Certificate of Eaemptlon,you s
Fshould become subject to the Workeri Compensation provisions of the Labor TOTAL:
f) Code,you nest forthwith comply with such provisions or this permit shall beBUILDING FEE - U //
W > droned revoked. '
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE I
Iherebyaffinn that there is a construction lending agency forthe perform, ELEC'T'RIC}'EE
M Z ' once ofthe workforwhichthis permit is issued(Sec.3097,CIv.C.) TOTAL:
02 Lender.Name PLUMBING FEE
LL I— Lrnder'c Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImAifylhatlhavemadthbapphcatiunand datethattheabovebfom hm '
6 Is comet.7 agree to comply with all :
city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID
>. W relating to building construction,and hereby authorize representatives of this
H city to enter upon the abovo-mentbned property for Inspection purposes. ALTER ORADDTO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cu partlno Date Recei t#
V
against liabilities,judgments,cops and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,M CFM) SUBTOTAL:
ag.i.tsaid City 1. nseq.a fl a ntingofth.permlt,
AIA HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
SI aWmof Applin/Con ctor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAL1R US MATERIALS DISCLOSURE -
Willtheapplicantorluture building occupant stare or handle hazardous HEATING UNIT(TO 100,000 BTU) Date -Receipt#
mperialaedefInadbythe CupegytA, Mu Ncipal Cod e,Chapter 9.12 and the
Plealih and Safety Code Sri ctIostf4S53I(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes /(k�NN
Will the applicant a,future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANg DATE
whlchemlt hamrdousalr conte Tanta ae defined by the Bay Area AU E�'fi®®
silty Management Distri BOILER-CAMP OI-E'OR 100,0(q BTU)
Yes( n p MAK (!8199U
vc read the haze nus materialere iremenb under Cha er 6.95 of BOILER-COMP(OVFR l00,Ofp BTU)
the Callfamia Health&Safety Code,Sections 25505,25S33 and 75534. I
undertand that l(the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQF.
responsibility to rally the occupant of the requirements which at be net tes of Cuwn+#--
prior Issuanceof.Cedificate nry. Q WY {'����
a
011or authodaed agent Date TOTAL: ISSUED BY: Uk
c
OFFICE,COPY