19874 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Budding Address:Bildin Proed Identification PERMWT NO. '
2. 219874
rsName: Phone: p
16 CITY OF CUPERTINO-BUILDING DIVISION Ci ,'I
r)IIxct/r,,.1
mrade . ma: ua.Nm: APPLICATION / PERMIT ( U
BUILDING-ELBCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL p
gineer. - Llc.No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add.Ad+��sf� rola( PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DE LARATION
I Ferebyaf(Irm that l am licensed under provisions o(Chapter 9(ournmem. APPLIANCES-RESIDENTIAL JOB DESCRIPHON
Ingwilh Se on7000)of Dlvblon3oftheButlncasand PmfessimsCode,and my
Iirems l.I.ful rce and eff.d. PANELS
Liren Gla U^ LIc.N
Dale Contractor H N.
ARCHITECTS DECLARA iN 201-1000 AMC'
IQ+�
re
Z I understand my plans shall be used as public records. OVERIODOAMP9 SQ.FI,FLOOR AREA $/SQ.FT.
E U[j LicensedProfessional SICNS ELFiCIRICAL
4 IL-0 OWNER-BUILDER DECLARATION SPECIALC UIT/M
Ihereby.i irmthat l am exempt fromthe Contractm'.Lkrense Law for the '
oo following reason.(Section 70IS,Business and Prof.kms Cod.:Any city or
0Zt" county which requbwa permamcwatruM alter,improve,demoRBh,orrepdr TT2vfP.MEA)$IRPCUIN&
anyawdure priorto l%Isuance,elsorequlrestheappllcantforsuchpermltm
9 Ole a signed statement that he Is licensed pursuant to the provbiom of the POWER DEV[
Olt Contractor'.License Lw(Chapter9(mmmenengwith Section 7000)ofDivi-
30�" don3oflhe Bualnesand ProfeslomCWd )orth.thebexempttherefromand SWRIEMING POOL E VALUATION
the bas%for the alleged exemption. Any Wolatlon o(Senlon 7015 by any TSSWI /
�Q appRcent(ora permit subjects the appllcanttoa civil penalty d out morethan OEH S 0 B'
five hundred dollars%W.
"4..' ❑I,as owner of the property,or my employees with wages as their sole E9D AL�' STOWE5 TYI'ECONSIRIICTION
tzQ compensation,willdothe wmk,.od thestrucame is rn,intended or offered for
F0 to&c.70K Bushes and Prfesiora Cade:TM Contractor.License Lw
$ does not apply to an owner of properly who Wild.or Improves thereon and OCC.GROUP RES.AMTS
who does such work himself or through hisownemployees,provided thetsuch
Impmvementsarenot wndedorofferedfwuie,lChowever,the Wildingor TOTAL:
Improvement%smldwilhinoneyearofcompldlorytheowner-bullderwlll have
tlg.tiurden of proving that he did notbulldorimpmve(orpurpmeo(sakJ. QTY, P $I PERMIT FEE FLOOD TONE APN
L j 4 as owner of the property,am exclusively contracting with licensed
cont.d.to construct the proim(Sec.7014,Butsirmand Professions Code: PERMIT INCE -
The Contractor's License Lw does not apply to an owner of property who
Wild.or improves thereon,and who contracts for such p(ojecb with• 'ALTER-DRAIN k VENT-WATER CEA)
cryg(ador(s)licensed pursuant to the Contnaoes Lhe se Law. FEE SUMMARY
LII am exempt under Sec B 4 P C for this reason BACK FLOW PROTECT.DEVICE OUTS[DF,FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner Dale RECEIPTp
WORKMAN COMPENSATION DECLARATION FIXNRFS PER TRAP SCHOOL TAX Y N_
❑1 hereby affirm that I have acertificatelconof consent d py theure,w• RECEIPT p
remficate o(Worken'Compewatlon Wuranrewaremlfled copy lhereol LSpc. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380,LbC.]p q 4
GollryY !.CTw ✓9` �a/��T DINGRECEITp
GAS EA.SYSTEMAVER 6(FA)
Com - BUILDING DIVISION FEES
�CeniRed copy%hereby th thehd. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertRld copy%filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKCRS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIDRM PA 20Ff Date Recei t#
(Thbsectlon need not be completed lithe permit b forom hundred dollars
(S10)wles.) WATER FIEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the performance of the work forwhich th%permit is loud,
I shall not employ any person in any manner w as to become subject to the WATER SYSTFAT/TREATING
Workma Compensation Laws of California.Dale PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei tN
Z O NOTICE TO APPLICANT:[(,after making this Certificate o(Exempllon,ysu
should become subject to the Workers Comper satlon provdoru of the Lbor TOTAL:
�'W Code,you must forthwith comply with such provisions Orth%permit shall be U NG 3 ' V
W 7 deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE s .a
Iherebyafflrm thattherebamrutmction lending agency for the perform TOTAL: ELECTRIC FEE
M Z ance of the workfor which this permit b baud(See 3097,CIv.C.)
V O Lder.Name PLUMBING FEE
LL Lnder.Addres QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW 1unify that l have read this appllcatlonad nate that theabme Information
S i.correct.I qme locomply with all city and county ordinances and dale lawn PERMIT ISSUANCE FEES PAID:
} relaing WWlidingmmlruction,and hereby.whorlu representatives afthts
F N dtytoenterupontheabo� ..tlondpropertyfwbapedionpurpows. ALTERORADDTDMECH.
? (We)agrcc to save,Indemnify an d keep harmless the City of Cupertino Date Recei tN
() airat RabWfes'aadgmenb,cosband expenses which may in anywayacoue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
g W1 old Yty 2.0neequenm o(the granting of thl.pe�* IL
3 '/_�Q AIR HANDLING UNIT(OVER 10,00CFM) CONSTRUCTION TAX 3S
vlureof Applicant/Contracto Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS I fATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 10,00 BTU) Date Recei t8
material as deBnd by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safely Cde Section 25532(47 HEATING UNIT(OVER 10,000 BTU) TOTAL:
❑ Ye. MN.
Will the applicant or future Wilding occupant use equipment or device VENTILATION FAN(SINGLE RESID) issT ATE
which emit ha.nlouB.it mnisi lr%nb a a de0.ed by the Bay Area Air Y P9
'•
Quality Management District? BOILER-COMP OHP OR 10,000 BTU -
4Yca 2R' 1Na BOILER-COMP 10,000 BTU) r n'\: x lI STI�LI
haBr read Health
Sfety Calde Sectlq equlreme5,2553 and255348.95 of ( y, I J�iU
theun Gltand t Health b Safety Cde,Rm cU a 25505,have
a t and 25534.1
rm not i Cytohat notify
the occupant
not thCrtlye
menta which
that b met NEW RESIDEMIAL hT[CFi. SQFf. q of relnPFfI[7p
P mibililylo nai(ylheoccvpant of the requiremeniswhich mustW mad int of l'un1 Ino
P or olsuance Ca Cate of 0.panty. -
/ 9'4
OwT or authorized agent DaTOTAL:
te ISSUED BY:
u d lA
OFFICE COPY