19859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES,— USE BALL POINT PEN ONLY
Building P piv Iden leaf n O.
PERMIT N
Badding Addm.s � 19859
/oe'So - Iz0
wnars oma: yTSJ'fionc:
PI _z Y7 CITY OF CUPERTINOLBUILDING DIVISION
Contractor'sName: LI,.Nm APPLICATION I PERMIT l 7
_... ' BUILDINGE.ECTRICAL-PLUMBING-MECHAMCAL' CATEGORY CONTR L
Archltect/Englneer. Lk.No:
Addreas:GO Lu. MI-IIIN AVC –SUiTb r�.�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
PERMIT ISSUANCE 14x� ® ®,
LICENSED CONTRACTOR'S DECLARATION I--�
I hereby affirm that l am licensed under provisions of Chapter 9(comma APPLIANCES-RFSIDENHAL JOB DESCRIPTION
Ingwith Sect1on70W)of Divislon3 ofthe Busineasand Professions Code,and my
license is in full farce and effect. PANELS '
License Class,J3-1 ic.NA 7:2 c/O'7 1 a )� jcw►J✓V
Data Contractor UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-IOOOAMIN
�p?0000 lunderstand my plane shall be used u public records ' OVER 1000 AMPS SQ.FT.FLOOR AREA N/SQ.FT.
E Licenssd Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION
'a� SPECIAL CIRCUIT/MISC
2: 1 hereby afllrn that I am exempt fromthe Contractor's License Law(or the
following reason.(Section 7071,5,Business and Professions Code:Any city or
O f:, TEMP.MEITIROR POLE INS(.
PanystmMchpq roup a=mi anamquia.thenpU=tfwsuch, erepair
q < any a algrure prlortollahat he
alsoredpursuea,to the provisions
of to POWER DEVICES
file a signed statement that he b licensed pursuant to the prowlona of the
kOS Conhanors License Law(Cha er9(mmmandn
O tt pt B with Section 7000)ofDivi. SWIMMING POOL ELECTRIC
F.30 VALUATION
tlon3of the Buelnessud Prolembna Code)orthat heisu
empttherc(romand
'g the bash for the alleged exemption. Any violation of Section 7011.5 by any
0 OUTLETSSWTTCIIFSHKTUR6
applicant fare permit subjectathe applicant to a civil penalty of not more than
five
hundred dollars(SW.
�a ❑I,as owner of the property, NEW RESIDENTIAL ELECIRSQ.FT. STORIES TYPE CONSTRUCTION
p perry,or roe'employees Ise with weed as their sole
t wmpenution,wBlda..mlthe kfiuslo and strucNrebna Intended License
d for
IUAw
e'^ q sale(See 7061,Business ant f property
Code:The Contractors License Law
$ does notapplytorkowner ofpropertywho buildslo employees,
vithereon,and OCC.GROUP RIS.UNITS
who dvdeuchworkts;amn notintended
edorough hiaore employees,providedthat such
Improvementsareno[intended earofe pletioe.If, cmer-ptheerwillbuildingorhave TOTAL:
Improvement issold within anayearo(completlan,the owner-bu1W erwlll have
thrise of proving that he did not build or Improve for purpose ofsale3. QTY. PLUMBING PERMIT FEE
ffL u owner of the property,am exclusively contracting with licensed FLOOD ZONE AI'N
contractors to construct the project(Sec.7096,Business and Professions Cade: PERMIT ISSUANCE s
The Contractor's License Law does not apply to an owner of property who
Wild.or improve thereon, and who convict. for such pwjeats with a ALTER-DRAW k VENT-WATER(EA)
�6t(a0 r(.)Licensed pursuant te,the Contractor's License Law. FEE SUMMARY
L.J I am exempt under Sec 9 k P C far this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
. Owner Data
RFS:EIrf N
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
tor hereby affirm that I have rFD(TURES.PER TRAP e a certificate o!consent
eel!-Insure,or RECEIPT N
e certificate of Workers Comperartion Imunnmma certified ropy theseof(Sec. GAS F.A.SYSTEM-I INCA OUTLETS PARKFEE Y N
3800,Lab C.) RECIgrI'N
PoliryM I.II Lr- t� a 19 GAS EA.SYSTEMOVER 6(EA)
ray _ - BUILDECEDIVISION FEES
"Certifted copy is hereby furnished. CREASE/INDU6TRL WASTE INTERCEPTOR PLANCI-IECICFEE
Certified copy is(find with the city inspection division.
CERTIFICATE OF EXEM PT ION FROM WORK ERS' GREASETRAP PAID-3-0-14D
COMPENSATION INSURANCESEWER-SANITARY-STORM F.A.p0pl• Date Recei t#
(Thissectton need not bra completed If the permit b forom hundred dollen
(SIW)or less) WATER HEATER W/VENT/EL TR ENERGYFEE Y_ N
. I certify that In the performance of the work(orwhich this permit Is bound,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
0 Z Applicant NEWRrMDENDALPLMB. SQFE. Date Rete) t#
11
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Worken'Compereation provbbu of the Labor TOTAL:
(p Code,you=at forthwith comply withauch provisions orthb permitshall be I G
Lu j deemed revoked.
FE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
0. Ibercbya!llrm thatthereba coratructlon lending agency for the perform- -TOT ELECTRIC FEE
M Z ane of the work(or which this permit is Issued(Sec.3097,Civ.C.)
V O Lenders Name PLUMBING FEE
F Lender's Address QTY. M ANIC PERMIT FEE,
LL U loncifythati havereadthbappliddonandltatethattheaboveinfomutlon MECHANICAL FEE
O W bcortect.l agrecto comply with all dry and county ordinances and date laws PERMITLSS NCE 11 FEES PAID:
} C relating tobulldingcoutruction,and hereby authorlae representativeof this - e
FN city to enter upon the above-mentioned propertyforimpection purposes. ALTERORAH.
Z Date Receipt#
(We)agree/o nave,Indemnify and keep harmless the City of ywaya erste
V
against CR, gments,co which my in any waysarue AIR IIANMI T(OVER ) SUBTOTAL:
agalsat Wd Cit cansequ the gr this permit. -
AIRHANDLING '(OVER t0,000CFM) CONSTRUCTION TAX
natureof Applicant/Contractor 3 >mtt. �— EiHAUSTHOOD Due CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous HEATINGUMT(TO1 , BTU) Date Reaei of
material as defined by the Cupertino Municipal Code,Chapter9.12,and the
Health and Safety Cade Seclon 25532(a)7 HEATING UNIT(OV ,000 BTU) TOTAL:
nYd No
�YIII the eppBcarat or ftmWilding occvpantuseequipmentordevices VEMDLATION FAN 1NCLE RFSID) ISSUANCE DATE
which emit ha,cardous air contaminants as defined by the Bay Area Air
Quality Management Dbtrlct7 BOILER-CAMP OFIP OR 100,M)BTU)
Yea ❑No
have read the ha>ankes materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
theCaliforniat Health h Safely Code,Sections25505,ve a tenant
understand rniaHhat Health
building fety Code not ecti ns 25505,ently 25 33and 25534 itismy NEW RESIDENTIAL MECH. SQFf. L
responsibility to notify the occupant of the requirements which must be met
prior to issua no,of a Certificate of Occu pa ncy.
Ownermit.thmind.gem Date TOTAL: ISSUED BY:=�lfvlli/II
OFFICE COPY