19320 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro W ldemifkatlaa PERMIT NO.,
BuiJolling 7180d- 19320
. 7�G�Z f-e3Tivht- �R .
-T h b(a-1 r)hero:4APPLICAr . . A A
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G41 Wb !/ 9p CITY OF CUPERTINO-BUILDING DIVISION
Contactor',N, me LIc.N. APPLICATION / PERMIT
J�(J BUIL.DINGELECTRKALPLUMBINC- E MCAL CATEGORY CO 1r
rchA ltca/FnI
Bine Nv.
o6co 7 Bb ICS Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. 63 134-Kete -PFRADTISSUANCE 1:1 F-1 -
❑
LICENSED CONTRACTOR'S DECLARATION
I Mreby Yfimthatlamlk'm.eduMerpm Wwaof Chaper9(mmmwc APPI.IANCES-RESDENIIAL - JOB DESCRIPTION
Ingwith Soctbn 7000)of Dividon3 edthe BuYneesMProfetlan,Cade,andmy
I ifull(orand d PANHR
License
konse CierIA a a LfcN
Date CoMuctor
ARCHITECT 5 DECLARATION AMPS
x2 Iunderst•nd my plane shall be used As public reach OVER I"AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
O SIGNSELECTRICAL
Iz�
Licensed Pro(mbvl '
�Q OWNER-EUILDER DECLARATION S�CIALCIXCUI.I./All's
eu2{, Ihercbyalflrmthat lamuemp from the Contractor'.Ucc
nateLawfathe
o qq�y following rtann.S EIm 70315,Bu.lnes and Pmfeabne Code'.My cityor
FmZ u,3 cvuntywhkhrtqulrtaapermlltommtmct,alwr,Impmve,de In h,ormpatr— METEROR TOLE ISI.
j � any•tructurtpAmt i0t amcalsorequMthe,ppBantfamchpemdtto POWER DEVICES
Ua we•Allred rtatement that he is liaved punuant to the provisions of the
� Conlra¢or',Lic'ense Law(ChapterI(commencing with Section 7000)of Did- SWEdMINC]00[, C
o slon3of the Buelne•mdI'rofeselov Code)orth•t heb exempt thcrtfrom•nd VALUATION
the basis for the alleged exemption. Any Nolatbn of Section 70315 by any ��-/ OQ
Og .ppU.1f,r•Permit subjeNtheappllcamm.dull pertaty dna morethan (T
fl ndrtd d.Rms(x500. NEW R LTR SQ-Fr. SIO FS TYPE CONSTRUCTION'1,u employees of the property,or my employwith wage,u their sole
compevation,willdothe wale andthesW cturc is not bderded or offend for
OWe(Sec.7DK Busln,,a and Pmlmloru Cade:The Contractors Wave Law
does not apply to An owner of property who builds or lmpmves therea,an OCCGROUP RES.UNITS
G wlmdoaeuchwork hlmrcUathrwgh hbownemplo�v,PrwWedthatu
Improvem Msartnot Intendedoroffemdfriars.If,however,tho Winger TOTAL
lmpmvementbraidwahinovyearofcmnpIMtb thownor-builderwwhave
14,korclett.fpsovingtihathedidnedbuildor knprove forpurpme of sale.). L BI IT FEE
L as owner of the Property,am excWelvely mntracHna. Ito, FLOOD%ANE APN
cantncmrs to mnabua tie project(Sec 7014,BusNe,•rd 1TYerIn.Code
Tv, ntn
Coaors License Law dm not apply to m owner d Property w AL.ITX-D WATER(EA)
Wild, or Improve thereon, and who cogracte (a such poo • --
cp4actnr(,)llcen•edparvraM to the Contractor's LicaBA .DEVICE rue law. BFEE SUMMARY
U I •m exempt urder Sec B k P C for this rtuon
Owner Date
DRAINS pirAbR,ROOF,ARG,COND. SANITARY Y— N_
WORKMAN COMPENSATION DECLARATION RTC- NN
❑I hereby.Hbm that I have a mrtlaate of mvmt to self-Inert,a a ETICIVRE"'PER TRAP SCIdOOL TAK Y— N
artlRT i—
Lab ofparker'CotnpevHm Ivurmn as artifled mPh'thertaf Sec RF(`- N
3800,lab CJ GAS G.SYSrEM.l WC4OUII.EIS PARK FEE Y N
Policy N GAS G.SYSEFM.OVER 4(G) RECEIPI.—
Car����p++++ny BUILDING DIVISION FT..rS
I Certwed copy b herebyfumle city GREASE/WDUSIRL WASTE INTERCFP'TOR PLANCHECK FEE 'I 1I C
/f�''Certwed copy b filed with tM city Ivpectbn division. (0y.Ao
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAI, PAID 1.
COMPENSATION INSURANCE SEWERSANITARYSIORM EA.31Q+r Date Reuel til
i
(TWA Yabnneed nghmmplded Bthe permh bfor one hundred dollars
(5I0()«Im.) WATER HEATER W/VENT/I]}ZTR ENERGY FEE Y N
l cony that lo the performance of the w'ak for which this pemllt b bucd, —
I shall not employ any penin In any manner an a to become subjea to the WATER SYSTEM/TRE1TIh
Workero enmperaatlon Laws of California. Date PAID
NEW RESIDENTIAL PLMB. SQFf.
Applicant
Z ZO NOIICETO come subject
to
he after maJdeg rs'Cam a .tion nerizio oftho Lathe Date ReceOTA tic
should become abjectto the Workers'.& res ialns.,v Npeofthe"N be TOTAL:
CC fn Code,
ternedyou rol,ed.forthwith comply with uch provlabv arthb permit Yellbe
W d«seed rewked. BUILDING FEE
a o COKSereIsa om uctionNOAGHCCY SE MIC FEE
thereby orkfthat(here i•ermIt ctla�lendingagency for the perfomm ELECTRIC FEE
7 Z mceof the work for which this permitls 4wM(5ec 304/,Cl,G) TOTAL
O lender.Name
i U _ PLUMBING FEE
LL F Leaders Aadre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W one . t.8me veresdthis ywith aBratlon•r purr rhaphe cess annfomulon aws
timing to agrefi to complywdh•11 herbmuntyo mpmardYcdth PQtMRI55UANCE FEES PAID:
} 4
relating rulpongmn,mm-nor,•ndherropauth«b rtption lvn of thLa _
N sly W)enter to ave,tove-me fy an d property f«inspection W ALTER OR ADD TO MFLH.
Z (We),lac to cove,LdemNty an d kaop humin the City of Cupertlre Date Recci tic
U eg,Wt Wbwtle,judgmew,mas•rd experm wnkh rvyln any w,yaaxue AIR HANDLING UNIT'OO IO,ODOCFM) SUBTOTAL
agawt as City in nor ortk gr•Mbg nrtw permlc AIR HANDLING UNIT(OVEIt 10,ODO CFM) CONSTRUCTION TAX
SI to of AppOvnt/ ontr,a Date EXHAUST HOOD(W/DLCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappOoM orfuturt Wfldingraupant Yore or hardle,hawdous HGTINGUNR(TO100,0)0BTU) Date RL'CCI IN
material as defined by the Orpertlno Municipal Cade,Chapter 9.17,and the
I le,llh and Sifety,Cade loc lon 75537p)7 HATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ye Na
WIIl the appllnv or 1]future building avrpant use equipment cedevim VENTILATION FAN SINGLE RESm) ISSUA[1LCF
which emit hazardous air contaminants as defined by the Bay Ama Mr r('V L
QualXy Mavgemev Dbtrict7 BOMERLUMP OHP OR IOQOW BT
❑ I)
Iham read the has.Imw.rMcrlaLr mrylremenU undo,Chapter 6.95 of BOILFRmMP rovl]21DT,000 BT11> JAN
the California Health 4 Safety Code,Sections 75505,75S33 and 75534.I
understand that if the buiding does not currently have.tenant,that It ismry NEWRESIDEN IALMECH. SQFT.
rapongbUlty to notify the occupant of the requbemente which must be not
procto/vuancociaCertlflnteofO=pancy. ` I Clrbx}a-/� rtnOrtrflnn
Owner or uthatzed agent Date TOTAL ISSUEDBY:
OFFICE COPY