19819 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buitclinut Prod Identification �1 PERMIT NO.
6ullddng Address: STr
D f1 cu m�I&t o t a �- �1.o -02�. 19 819
�^ 1'�i/ Phone: p
EI.v LC ` ry'L {q ell 4'P-10525CITY OF CUPERTINO-BUILDING DIVISION
CerVaQOu`BN.rv; Lic.Nu APPLICATION I PERMIT
BUILDING-ELECnUCA4PLUMBINGMFLHAMCAL CATDCORY CONTRQG,p
Arthilect/Engineer. Le.Nru
E mAt AN•
QTY
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Il000 WUL
Aaarcew PP.RMITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby afflmt that l am licensed under provisions of Chapter9(exmmenc. APPLIANCESRF.SIDENTIAL. JOB DESCRIPTION
IngwithSedion7000)af DlWslan3ofthe Bust.ssand PMfessionsCode,and my
license is In full force and effect. PANELS T
"License Chid Lt.Y e 1 s
Date Contractor
. UP TO 2DOAhMS
ARCHITECTS DECLARATION 701-1ODO AMPS
po+D❑O Iundentand myplarushallbeuaed aspublicrcoords. OVERI000AMaS SQ.FT.FLOOR AREA $/SQ.FT.
E (/ Licenard Professional SIGNS ELECTRICAL
«<< ku OWNER-BUILDER DECLARATION S[+ECGLCIRCIIIT/MLSC
t., Iherebyaflresthat lamexerept frem the Contractor's Ll.nar Taw for the
pO following reawn.O ISectlon70115,Business and Professions Cade:Any city.,2 r
r countywhich requeesapenNtwconstmci,alter,lmprove,demohh,ar rcpalr TEMP.METER OR POLE INST.
a any stmcturcpMrto its Wsa.e,elsorcqulmthe appauntfm each permit to POWER DEVICES
V file a signed statement that he Is licensed pursuant to the provide.of the
Ou. Contractors License Law(Chapter 9(commencing with Section 7000)of Diel.
301{� don3 ofthe Business and Pmrsalo.Code)orthat helsexempttherefromand SWIMhBNGIWLFT.EC[RIC VALUATION
�'^' the basis for the alleged exemption. Any violation of Section 70115 by any
<5 OUTLETS-SWITCHES-FIXTURES fora permit sub'FctstheaPPlicant to a civil penalty tyofnot mercthan
�� dI QOO
flue hundred dollars he Pr, NEW AFSIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRVCTION
❑I,as owner of the property,or he employees with wage as thele wk
m1.&c.70Kmpensation,wilBu Bathe of rk Pro and thes Code:Th nm Intended or ioffend for
doe net
tapply to show owner
of prep"
Code: CImproves Limn.law
and
who notstich oanownerofthroug hiswho
nemporlmprovescied that
ryuch OCC.GROUP RES.UNITS
whodoes
erds amrkhlmsended or offered
Neowne.If,h es,p ,the building or
Improvements ofld ithindneyear fcomplsion If, mmer.bu Uderwilingm TOTAL:
Improvement hsold within oneycarofmmplation,the owner-bullderwlll have
Xnn of proving that he did net bund or Improve for purpose of sae.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
s owner of the property,am exclwlvely mntnedeft with Bernard to construct the project(Sec.704A Business and Professions,Cods; PERMITISSUANCE
The Contractor's Lt...Lw does net apply to an owner of property who ALTER-DRAIN h VEM-WATER(EA)
Wilds or Improves therem,and who mntraM for such ptojecis with a
oris)Burned pursuant tot Cont aLi.c.L.w. BACK FLOW PROTECT.DEVICE FEE SUMMARY
exempt under Sec. B&P C for this mason
Owner - DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Date g_Ng
WOR KMAN COMPENSATION DECLA RATION FIX.NRFS PER TRAP SCIdOOL TAX Y N
❑I hereby affirm that I have o udlFlute of consent to copy
there. (Ne RECENT 0
certificate of Workeri Couponsatlanl.urenuora.nl(led copythereo(fSec. GAS EA.SYSTEM.I INCAOUILET3 PARKFER Y N
Polis # C.)
Comooan GAS FA.SYSITMAVI:R4(EA) RECm'I'N
o0oo Y BUILDING DIVISION FEES
Cor if rd copy 1.M1ereby th the city GREASE/1N STILL WASTE IMPAC TOR PLANCHECK FEE
CertlFled copy h(hero with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEWER- ARY-STORM EA pmrT Date RL'cei tN C7 C7't
Rhieaecien need not be completed lithe permit h Toro.hundred dollars
(St 00)orf
Icerti(y,y thm
thmat In the perfoun .itis work for which this penult is heWATERW/ved, /EU' ENERGY FEE Y N_
I shall not employ any person In any manner n.to become mbj d to the WA /,Rt ,DNG •Ijol
Workers'Compenssbon Uwsof California. Date PAID W 7 "f
O z Applicant ALP Date Retei til 1st60
Z NOTICETO APPLICAM:IL after malting CertBlute of Exempllon,y
Hshould become subject to the Workers'Compensation pmv o.ofthe Labo i TOTAL:
N Code,you most forthwith comply withsuch provide.ort permit ahold be i
j U D G 7' "50
W deemed Invoked.
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
s d Iherebyafflrmthat there h a co.emction kndingagency ,the pert I ELECTRIC FEE
V0 arm of the work(orwhkhthh permit hlamed(Sec.3097,Civ. .) TOTAL: PLUMBING FEE
Lender'.Name 1
LL F Lerdcea Address t MEC ANICA PERMIT FEE MECHANICAL FEE
O W1wrUfythatl have madthis application and nate lhattM1eabove in o
4 Isconact.I agree to comply with all city and county ordinance'and RISu^UANCE FEES PAID:
7. miating to building co.4uctioe,and hereby authori.repreP-c",
U) city to enter upon the above.mentenei property fee bupec0ALTER OR ADD TO METH.Me)agree to save,indemnify an d keep harmless the Cuo Date Reeei t#agaeat liabilities,in dgments,mats and expenses which may Icrue AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL'
against said City In mrxquena of the granting of this pe
' AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signawreof Applicant/Contractor Date E%HAUST HOOD(W/DLJCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant or future building occupant store or handle hazardous HEATING UNIT CIO 100,000 BTU) Date Reset t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,"BTU) TOTAL:
❑Yes No
Will the applicant or tare Wildlngocmpantuseequipment ordevices VENTILATION FAN(SINGLE RESID) I]ANCE DATE
which emit harardous air contaminants all defined by the Bay Area Air r
lily Management DistrlciT BOILER-COMP DM'OR 100,010 BTU)
Yee ❑No pQ p
a ave read iheM1azardous maderlab rcqulrcmente undcrChapter 6.95 of ItOILER-COMP(OVDi 100,000 BT11) '4• tT d
the l7Bfomh Health k Safety Cade,Sections 75505,75511 and 25510.I 7 T33J
L�hunderstand that lithe building does not currently havealrnanLthat itis my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the past of the requirements which most be met
P oor Issuance of a Cee flcate of Occupancy. 'G
Owner or authorized agent Date ISSUED gY.�I-!(may \yam
TOTAL:
OFFICE COPY