19904 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 19904
z3a3 rrcZeT rLL-
srs ante: Phone:
db u��T 1q CITY OF CUPERTINb-BUILDING DIVISION ��7i SIO
N : APPLICATION /PERMIT 7
•. a A't 6 y BUILDING-ELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Archiled gleesr. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMIT ISSUANCE �.Ie ❑ ❑ ❑
LICENSED CONTRACTOR'S pr DECLARATION of
ChON
Ihereby aH .70that Dimi,i 3.fthnderprovlalonsoffh..r9(comnkne- APPLIANCESRESIDEMIAL JOB DESCRDeITON
Inccsa is in fon 7f100)of d dieon3ofthe Businessand ProfeWoneCode,and my
license Isla(u o d c,N So9' PANELS • h'
Llate LION es ^,n r
Date Contractor ♦ h•`
ARCHITECPS DE LA TION Nil"1000 AMPS
q�v otO ZpC I understand my plamsha0 be used m public records. OVER1000AMPS SQ.FT.F1=RAREA $/SQ.Fr.
Licensed Professlonsl SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
SPECIAL CIRCUITAAJ -A
z � Iherebyafflrmthatlamexempt(rom the Contractor',License Law for the
02-N following reason.(Section 7031,5,Business and Professicns Code:Any city or TEMP.ME TR O
rrEI county which mluimsa permit to construct,alter,Improve,demolbh,orrepafr
q an ystmdumpdortoltslssuance,alsorequimstheappbanlforsuchperMtio POWER �0�
P C file a signed statement that he b licensed pursuant to the provisions of the
H5OkG Contmdors License Law(Chapter 9(commencing with Section 7000)of Divi. SWIhm FOO
1 slon3 ofthe Business and Professions Code)orthat hale exempt therafromand VALUATION
0$ the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS FIXTURES I /t
appllcant fora permit subjedsthe applicant to a civil penalty of notr=lha^
$ five hundred dollars(4500). NEW R L ELECTR
nI,as owner of the property,or my employees with wages as their wle STORIES CONSTRUCTION
compensation,will do the work,and the structure is not Intended or offml fpr
Osale(Sec.7614,Business and Professions Code:The Contractors License Law
[fid $ docs not apply to an owner of property who Wilds or Improves thereon,and OCC.CROP RES.UNITS
0.0. who doessuch work himself or through his own employees,provided that such
Improvements arc not Intended proffered fursale.If,however,thebuilding or TOTAL:
Improvementia idwlthlnom)carofcompldion,lheawner-bWiderwlllhave
t"rden of proving that he did not build or Improve for purpose of axle.). QTY, PLUMBING PERMI FEE FLOOD TONE APN
Lj L as owner of the property,am exclusively mntrading with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: -
The Contractor's License law does not apply to an owner of property who
Wilds or Improves thereon,and who contras for such ptpiects with a ALTER-DRAIN&VENT-WATER MA)
%B¢acmrts)Ilrenaed pursuant to the Cpntradors Lincs.Law. FEE SUMMARY
IJ am am exempt under Sec. 0&P C fpr this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
•. Owner - Date RFLED'TN
WORIOHAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
01 hereby affirm that I have o certificate
anc of consent m opytnmre,ora RECEPT N
certi(Imle o(Werkens'Compensatlpnlnsurance ora certified copythereof(Sec. GAS EA.SYSTEM-I INC OUTLET PARK FEE' Y N-
3 lab G. /N RECEOxC N
Go1iry N y GAS EA.SYSrEM.OVER 4(EA) BUILDING DIVISION FEES
Com env
ffCe pyGFereby fumished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F1 Certified copy d flied with the city imperf division.
CERTIFICATE OF EJ(EMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE ShWEIbSANITARV-SANITARYEA NIOFf Date RCCCI lM
Rhbeection need not be coesplded if the perrmt Is forms hundred dollars
(E100)mfthat
mwhichthismlovWATER HEATER W/VENT./m rrIII ENERGYFEE Y_ N—
I
certify that In the pedouncee(the work for which a pedt Is loved,
_ WATER
shall not employ any person In any runner an as to become subject to the WATER SYS.IEM/TREATING
Workers'Compensation Laws of CaBfornla.Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ.FT. Date Recel tit
Z O NOTICETO APPLICANT:ILager making this Certificate of Exemption,you
should become subFd tothe Worked Compensation provisions of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orchis permit shall beB I TNG •E c
W j deemed revoked.
Q. CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 O
T hereby affirm that hem Is a construction lending agency forthe perform TOTAL: ELECTRIC FEE
j 7 Z ance of the work for which this permit 0 issued(Sec.3097,Civ.Q
U O LendH',Name PLUMBING FEE
LL I- Lender',Addrx QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iceddythatl have read thhappinformationtionand statethatthe above information
6 1100ned.I dgnm to complywRh all city and county ordinances and state laws PERMI7ISSUANCE FEES PAID:
>. N relating to building comtmction,and hereby authorlaa representatives of this
Z city to enter upon the above-mentioned property for Impaction purposes. ALTERORADDTOMECH. Date Reeei ttt
(We)agree to save,indemnify an d keep harmiess the City of Gu ped Ino
V against liabilities,judgments,cons and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agai id City In run of grag of this permit
O AIR HANDLING UNIT(OVFR16,000CFM) CONSTRUCTION TAX
7
rS tureof Applicant/C radon to EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZA US MATERIALSDISCLOSUR
Will the applicant o heurebulldingnicipan ode, hapten 9.h,and
HEATING UNIT CTO 100,0008711) Date RCcei tN
material as defined by he Cup�t1Ino Municipal Code Chapter 9.12 and the
Ikalth and Safety Cpdnn25531(a)7 FIGHTING UNIT(OVER 100,000 BTU) TOTAL: J✓
Yes No
Will the applicant or core building occupant use equipment ordwicea VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardousalr con la nls as defined by the Bay Area Air - a� -
Qualty Management Dlatrid BOILFR.COMP OHP OR 100,IXq BTU) �N
. ❑Yes o �'
' Ihavc rcadthebav, pus ma Hats requlrerre^b under Cha per 6.95 of 001LER-COMP 100,000 BTU) MA
the Califomla Health&Safety Code,Sed loss 25505,25533 and 75534.I
and crate rad that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECIL SQFr. C—Dy?tx
responsibility to notify the or d the requirements which mu at he met �r
ori to Lvuance o(a fiat o p gray of f0s•a-
ner or authorleed a Difie ISSUED BYmla 1- �s`a a�-/^'�/
TOTAL:
OFFICE COPY