19420 APPZ" ANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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�- 19420
MENV G
s / CITY OF CUPERTINbBUILDING DIVISION i1 r��QO
Contractor'.Name: Lk.No. APPLICATION /PERMIT
AmhltM/FBNL.DINGF7.0.:IlUCAL1'LUMBINGMECHANICAI. CATEGORY CONTROLYf-Y�
Lk '
G" BUILDING PERMIT INFO
� Q ELECTRIC PERMIT FEE
A PERIA"C IS6UANIX ' .V� ® ❑
LICENSED CONACTORS DECLARATION
I hereby sTR
f(Irmtlutlam Bcrosedunder provLNons of Chapler9(momma APPLIANCES-RESIDENTIAL B N
hIncegnwsdh1.5i«n 1f1uolnlforona nJeff on dtheBudnnsand Prole.donsCade,and my PANES
L1cvr.C" Ic.4
Date Codraaor !!teail aI dI
L D
D
C
ARCHITECT`S
DECLARATION 201-100QAMPS
Poi.WPaO�V I understand my plans shall be used as publlct— & OVERIWOAMPS SQ.FT.FLOOR $/SQ.FT.
y(/ Lkxnud IhofemI lonal SIGNSELECTRICAL I q V M� 71 [ 2—
OWNER-BUILDER DECLARATION STid�LCIXCl11l,/h'� 1111
Ihenbysfflrmthatlamexempt fromths Cadradari Llrxnse Law(«the �D ^ `�D
pp following reason.LSection 70715,Bushes and Prefessbns Code:Any city or
67 TEMP.METER OR POLE WST.
P� county which requtresapemdt to mru.ud,alter,tmpmve,demolish,or repa7r ll �p�1��17 I
q any wmctump or to its i.n„�ae,aEto requires the applicant for such permh to ppypR DEVICES
FSO 0.S flk.dgned.ntement that he is licensed pursuant to the prevbbns of the
Contractors License Law(Chapter 9(mnmercing with Sm n70W)of Dlvl- SWIIMNG IC)OL ELECTRIC
dNemb
I O;} on3 ofthe Business and PrreCode)orthat he b exempt therefromand VALUATION
I •77 the bub for the alleged exemption. Any Wdatbn of SMbn 7m1S by an
appllwt fora perndtsub*e theapphcanttoadNlperahydna morethan OUTLETS FIXTURES �[ r oG
ffve�hundredddlars%5 W. NEw l V
�n Lf 1,as owner of the property,or my employees with wages u theb so '`�'FT' STORIES TYPECONSTRUCTION
mmpcns im,wiRdotMw "ndtheammm Lrmtlntendedoroftertdf
D ®Ie L5oe 7044,Buelrcae.nd lMrslons Code;The Codnaor'sllnme
( 8 don not apply to an owner ofproperty who builds or Improves them d Tj
/ OCCGROUP RES.UNITS
EE whodons.chworkhUmelf«thwghhbownemployen,provbcdth t do / �yy...aaa
imprwemew an curt lntendM oro(fend(«sale.IL hmvever,thebaild 3.3 ' /—
ImprovemendissddwkhlnoKyurvfcompldbntheowner ve I`
tl�urdcn of proving that he did not build or improve fee pa sale.). QTY, PLUMBI FEE FLOOD TONE AIN
u I,as owner of the property,am euhmiwly oontracnng with 14xmed PERMIT LSUMCE
contractors to romtmd the project(See.70th,Bushes and Profesbv Cotle. -D()
The Comeamri License Taw does nes apply to an owner of property who ALTER-DRAIN k VFM- ATEt(FA)
builds or Improves thereon, and who mrdnda for such p(ojMs with s DO
rypj[+ctarW B«nsd pursuant to the Contndo's Wrenn Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec B k P C for thin mason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
Owner Date RECEIPT I
TWq WORKMAN COMPENSATION DECLARATION ""TURFS PER TRAP Q SQi00l TAX Y_ N
rcF yRlaeof War4en.'Caffirm at I have a ompenutimr Wunnta«saM(led copytM1enof tsec. REIZ=L
38W,Tab C.) �r , may GAS EA.SYSTEA WCN_
-1 4OUTLE S PARKME Y_
Polity I N(7 J e'of� '
or, `Y/R RECEPI'
Cn��m..pp++nGAS EA'SYSTEM-OVER 4(PA) BUILDING DIVISION FEES
,Verified copy b hereby furnished.
�Certifiedropy b filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERT67ICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID I
36a
COMPENSATION INSURANCE SEWER- STORM EA.aWET Date Recd tit
(Thbeeclbn need nes be eomplded Btk permit b fa arae hundred dollars
M00).,
W)«fythIess. WATER HEATER W/VENT/ED= ENERGY FEE Y - N—
I
that in the persninaerformance ofthe work so as to bthispemdtisissued,
]soak not rmptoy any Person In any net at u m become ubJax to the WATER SYSTEM/TRFATENc
W«kcrs'Compewtbtu
n Las ofGW«nis. Daze PAID
O Z Appbcant NEW RE DFN A PLM.. SQFT. Date Red tit
Z O NOTICE TO APPLICANT:E,after rruldng this Certificate of Faemptlon,you
should become subject to the Worker:Compensation provisions ofthe Labor TOTAL
~ N Code,you oust furthwdh complywith such pnovbbruorthis Nmdt shall be BUILDING
LU j deemed revoFEEked.
LUp CONSTRUCTION LENDING AGENCY 5EISMIC FEE
d Ihereby affirmthat then b•mnstructlon bMing agency for the pedorm- 3 �D ELECTRIC FEE
Z ..of the work far which this pemdt b Loved Sec.309'/,ON.C.) i TAL 33a
00 lenders Name PLUMBING FEE A
IL L nder:Addrs.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0(�
O W iced BythazlhavenadlhbappB tlon•ndnatethattheabovelydormnim )
y loco.mt.Iagrntocomplywce,imckyandco�n iruncnandlatelaws ISSUM'CE ,L.dO Fees U 3y
} rel.ingtobuildingmnstra ,and heneyys o npmtentativnofthb
F Z dty to corn upontk abovcme tis p'mpery for pedbn purpo.n. ' ALTFRWMECH.
D0Date Revel (#
— (We)agree to ty. d keep ha ess thecity of apertlno Paes Wtl e,conn expen may In anyvnyacvue AIR ITASUBTOTAL:rns of agaf thin pemNt' AtR FIACONSTRUCTION TAX
Sig root ppedant/ ntrxto Tate FRHAUCONSTRUCTION TAX PAID:
HAlARDOU A IA LS DISCLOSURE
WllltheappBcardorfuture 0 occupant store or handle havrdoue HEATWG UMT 1 BTU) Date p
material as deRned by the Cupertino Murddpal Code,Chapter 9.17,and the
Health and Safety Code Section 755324)7 HEATING UNIT(O 14),000 BTU) a 70
❑ Yes riNo
Will t he applica nt or futu re building occupant use equipment or deviub VENTIIATTOX�AN(5 .LE REBID) I rYc gATT�
which eMt hanrdvus atr mntambanbu defined by the Bay Are.Air X"J a7TJ7 r�
�+ 10.yy h(arugemeM District? Boa cR POEN ORIA"BEEF) u
L�Yn ❑F�I NoArk
(have nod the huardaus rtatrdais requlrtmenb under Glupter 6.95 of BO OMP(OVERIW, SN)
the C.Iff.la Health k Safety Cade,5edtom 755A ,25533 and 755M. I r 3v)lw�
understand that lfthebuilding does not currently have a tenant,that It Lt my RESIDENTIAL MECIL SQ.PT. �•:+a/
rnponvlbllityto naltythe occupant ofthe requirements which must be not
-- ''Priorto Issuance c(a Certificate,ofOrcupancy.
Owner«authorlud.gent Date ISSUED BY:V e D*VZ
-�.��tA)^'V
T7TAL D
OFFICE COPY
46CITY OF CUPERTINO
INSPECTION DIVISION
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