19718 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pra'ed IdenHfleatlan - PETLWT NO.
19718
B�IONng Oddness: '
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B Pwa.� YOVL+ 74.3-u/SG CITYOF CUPERTINCLBUILDING DIVISION !`1�
Convactd,Name: I .No: APPLICATION /PERMIT
�. BURRING-ELECIRICA1,PLUMBINGMECFIANICA1, CATFLORY CONTROL Y
i,rehhm/Psglneer. Llc
N.
QTY .ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. 11l'umb m=
PFRMITISSUANCE ❑ ❑
LICENSED CONTRAC(O WS DECLARATION
I hertbmthat laesed order APPLIANCESRESIDFNIUL
Section 7WoromonsRDESCRUMON
IngwithWfDlvWm3oftheBualnem , y
Lienee V in s fora and effect.# PANELS t- -��.rj LL�.A�s,?
Lcense,Clam LfcY W,C a7 `+aKVo"a�C, N��
Date Contndor UP TO 2DOAMPS '
ARCHRECL'S DECLARATION AMPS
qNZ lunderstandmyplamshaUb uaedaspubhcrecmds OVER 1030 AMPS SQ.FT.ROOR AREA $/SQ.FT.
O
Fi z Lk nxd Professional SIGNSELBC'IRICAL -
<<�< OWNER-BUILDER DECLARATION
CyhLm2CU1T/MISr
]f, Z Iherebyafflrmtlutlamezemoframlhe Contmoor'.Lber Uwfwthe
pO foBowing...(Section,90315,Business and Pnfemines COle:Any city or
O L rqqq TEMP.MEIE7t OR POLE INST.
rr4�� counrywh'ih requirsapemMtommtsuct,alter,impmve,demoLLshorrepalr
my ltwcturepdmto ltabmanec,alsoand pursuant
t favisto.rI to POWER DEVICES
O file a signed tlate�M the M V 11¢nsed purw.nt to the provbloro of the
0u.r Contractors License Law(Chapter 9(connencingwith Section 7000)ofLIM-
F,301 alan3 tithe Businenand PMembro Codc)orthn he h erenpttherefnmaM SWIMhUNCIWLE.ECTRIC VALUATION
a f5�n the basis for the alleged eimmptlun. Any violation of Suction 7MI5 by any -
app0ant(ora perndt subjects Neappllcmttoa tlWl perohy otnor more than OIJD.ETSSWTICHFSFlXTURFS
Bv
Ic c hundred dollan(S.M. NEW RESIDENTIALELFLTR SQ}T. STORIES TYPECONSIRLCTION 1
]�n I,as owner of the property,or eny employees with wage u their sole
compenuHon,will do the wo,k and the structure is not IMerded or offered for
psale Lee 70K Bu,irosand Pmfedom Cada:The ContncorsLI¢me L+w
$$ does not a pply to an owner of property who Wilds or impnovnthereon,and OCC.GROIII' RES.UNITS
who dao such work himself or through his own employes,provded that such
improvcmcrds are not Intended oroffered for sale.14 hwvcver,the building ce TOTAL
bnprovennent 6sold within one yearofcompleder,the owner-builder will love
flit*rd of proving the he did net wild or improve for purpcae Of sale.). QTY. PLUMBING PERMIT- FEE
L a.owner of the property,am eocloevIly,contracting wish licensedFLOOD IDNE APN
contractors to construct the pmJM(Sec.713K Bunnem and Profewbro Code: Pi ISSUANCE
The Condnctorb License Law dm nor apply to an owner d property who ��(-DRAIN A VFM'-WATER(EAI
Wilds or improves thereon, and who cordram f¢such pk jees whh a
c911LIO or(s)B¢nsM pursuant to the ContraC¢'s Liana Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am se-pt under Sec B k P C for this reninQUTqInFFFFq
Owner_ Dale 0[RAINSFIOON,ROOF,AREA,CON I. SANITARY Y_ N_
ORI C .I F SATION DECLAR TION RECEIPN
Sl .❑l herebbyy affirm n I 1 a¢rtlfiate of consent to self-Wore,¢a FI%TURES I'ER TRAP SCHOOL TA% Y' N_
cenlflate ofWorken Csnperoatlon Ivurana¢•¢n Wed o>py thenrof RECEIT
3800,Lab C.) GAS-EA.SYSTEM-1 INCL OUTLETS PARK FEE Y_ N_
Policy GAS FA.SYSTEM-0VERI(FA7 ^ RD=0
Com ray a�a� BUILDING DIVISION HES
�Ccrtified copy Is ft"thereby
thOch. GREASE/MDUSTRI,WASTE INTERCEPTOR PLANCHECKFEE
❑Ccrtdled copy b llled Mth the city inspection division.
CERTIFICATE OFIXFTIITION MOM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFRSAMTAAY S]ORM EA 2(IQT Date Ricci [N
(Thin section need net be camplMd if the permit Is f¢ane hundred dollen
1ENERGY FEE Y N
(SLOW¢IerJ WATER HFATER W/VENT/ELECfR 2.�
certify that of this penmliebwed,
1 ah U n¢empty any pen m any miner w n w beconr object to the WATER SYSTEM/TREATING
Worl,em'Compensati nlrws of GWonia. Date PAID
PP NEW RESIDENTIAL PLMB. SQ.FT.
A II.I
Z O NOIICETOA['PLICt to
ager Certificee pro Of isomoftlo Lyou Date Recel tk
should become subject to the Wonken'ComperuMbn pmvialoro of the Labor TOTAL:
Q N Code.you.9forthwith oanply with such provislOroorthls Perron alailbe G
W
> deemed revoked.
FEE
CONSTRUCTION LENDING AGENCY SEI IC FEE
d I herebyafRrtnthethereisaconavucUm leMingagencyforthe perforrry ELECTRIC FEE
m
= arta of the work for which this permit b Issued 65ee.3097,CW.C.) TOTAL ',��
V 0 lender's Nae PLUMBING FEE c�
LLF I<nder'aMdrsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
O LU I¢nlly WtlhavemadthbappeatlonaMatatethattheabovelnformaum
brorrea.l.greeto c¢nilly wltn.n dry.M ro„nryordwn¢aana r,telawa PERMIT ISSUANCE FEES PAID:
} relatingto Wildrigcomtsutllon,and herebywthorice repmentseves Ofthh ,
F cdytoenterupon ted above-mentioned W
property for penion purposes. ALTFRORADDTOMEFL
C
Z
(We)agree to Ave,indemnify an d keep harrol m the Clty of Cupertino Date RecciptIf
V agalmt habWtles,Ndgmew,crosaM eapernses which mryinanywayamue MR HANDLING UNR(TO 10,000 CEM) SUBTOTAL:
against said Cny In conampti.ed the grant Ing d this pe.ft.
AIR HANDLING UNIT(OVER I(%=CF.AD CONSTRUCTION TAX
S Sneum of Applicant/Contractor Date FXI IAl15T HDOD(w/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappBeed or future wilding oavpantnon or handle harandoua HEATING UNIT(T0100,000BTU) Date Recei tq
matcmial as defined by the Cupertino Municipal Code,Chapter 911 and the -
Fleahhand Safety Code Sectlm25531(a)i HEATING UNIT(OVER I0l1,0Dl1BTU) - TOTAL:
�Yes No 111
W the applicant or glum Wilding occupant use equipmeru«devices VENTILATION FAN$INGLE RESID) ISSUPSAMTE
which emit l Ovedc u,ab antamW Me as defined by the Bay Area Air -
QualityManagementDistrN? BOILER-COMP PHPOR 100,0(0 BTU) Q
n n
.` Yes rIO No r 1i Fit
FO J '
``((have read the hav ,materials requirements under Clupler 6.95 of BOILER COMP(OVER 100,000 RM
the rAlUornla I1eeth k Safety Cade,SnAicru 255(15,75533 and 25534.1 -
understandthatifthebuildingdoesnotcurrentlyhaveatenantthatitlsnry NEWRFBIDENTIALMECYL SQFT
retporulblllty,to notify the omapant of the requlrcmeNs which must be met J
prior to Lmuarm c(a Certfiatc of ocupanry.
Owneror suthodud agent Date r�,c �,
TOTAL ISSUED BY:u k--�rl V�avu�
OFFICE COPY