19696 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prded Identification - PIRMITNO.
Building Address: -
X02-13 Jos+:.PEI c 2cLE L. o-r 3 19
wmn ams: one:
JOS-ULA Tapxk A5$OC,.' 7-3•9'4 Q, CITYOFCUPERTINO-BUILDING DIVISION �—� 3- SIO
en adrr.Nam: uc.Nm„ APPLICATION / PERMIT
• ��SES SIS IG d ZQ�.S' BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY i CONTRO
hitect/Eagineer, c L .Nr: L
Arc
�N C-1—L0747C' / QTY " `ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 0 A W G q
PFRMRTISSUANCE
LICENSED CONTRACTOR'S DECLARATION lc
Thereby affirm that am licensed under provklons of Chapter 9(commem. APPLIANCE4RESiDENTWL OE DFSC ON
ingwlth Sedion7000)of Dlvislon3ofthe BusinemandProfemionsCode,and my
Limosealnrul eenaefd.
PANELS ��D`JL /rW� �
Lconse Clam-�Lkect. - �L�I"S� 1 s C
air. 701-1000 AMTS
ARCHITE CLARATION -
1q�a0 O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA �•. f/SQ.Fi. j
k Licensed I'mfosomal SIGNS ELECTRICAL' I STS LI V I N v
OWNER-BUILDER DECLARATION a lhcrebyafflren thatlamexempl fmmthe Contractor'sLicense Lawforthe 9aECIALCRtCIRT/MISC r •
( W�
17p i0 following reason.(Section 7031S,Busineasand Pmfmkns Code:Anydtyor
OZ TEMP.METFdt OR POLE MSI. 4O0 ^ ITC K�
county which requires apertNl to construct alter,improve,derlbh,or rcpalr -
g any St ructurepatercoltshat he
licensed
pursuant
to the frr,lgons of
POWER DEVICES
,.FJ ryE + �'•- file a signed statement that he h 1lansad encirit it the provision of the _ -
3w Contractor's License Law(Chapter 9(romrrcndng of Divi�
I,�OS ebn3 of the Businen and ProfemlomCode)orthal he bexempttherclromand SWIMMING POOL ELECTRIC VALUATION
O 5 the basis for the alleged exemption: Any violation of Section 70715 by any OUTLEIr SWITCHESHXTURES / i �f�� -
appEantfora permit subjectitheapplicamm.civil penatyefect morethan ai •� v
five hundred dollars($500). SQ y�,o' STORIES TYPE CONSTRUCTION
�n QLas owner of the co NEW RESIDENTIAL ELECTR .FI,
p ork,a or my employers with wage as their for
ask(Secompee.
wllldothe work,and[hestructure Code: he Contot ractorendeds
or kens offeredeLaw
sale(Sec.apply to an ow and f pmpa ty Code:The Contractors ves hemon Law
,$ does notsuch toanowner ofprough iso nem orimproovidedthat bed
�$^ whodrneuchworkhimael(orthrrugh hlaownemployees,pravWedthatsuch - OCC.CROUP RFS.UNITS
Improvements are not Intended oroffered formic.IL however,thebullding or TOTAL:T9.07
improvement bsoldwithin oneyearofcompldlomtheowner-bullderwlll have
t)I of proving that he did not bund or Improve for purpose of sale.), Q1Y. - PLUMBING PERMIT FEE
U L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the project(Sec 7064,Business and Profasslaa Code: PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who ALM-DRAIN kVENT-WATER OW
on
or Improve thereon,and who contracts for such p,."with a FEE SUMMARY
on ttracircle)licensed puma.[to the Contractor's Lt..Law. BACK FLOW PROTECT.DEVICE
U 1 am exempt under See. B dr.P C for this reason
Owner Date . DRAINS FLOOR ROD$AREA,COND. SANITARY V_-N
. WORKMAN COMPENSATION DECLARATION RECERII'N
VI hereby affirm that I have a anificate of consent to self-Insure,or a FAT RIES PER TRAP SCI TOOL TAX Y_ N'
dAMmleofWork m-CompewtionlmumnaeonmrtBkdcopythert f$eec. RECEIPT
3800,Iab C.) GAS EA.SYSTEM-I INC.4 OUTLETS PARK FEE Y_ N'
Policy N RECEB'I N
Co any l GAS .SYSIFMAVER 4 AR
ABUILDING VISION F:IiS
�Cecti ed copy lshereby furnish ad. GR / TRL WPLANCHECK FE
IDI Certified copy Is filed with the city inspection division.
Y�4 CERTIFICATE OF EXEMPTION FROM WORKERS' G r PAIDCOMPENSATION INSURANCE SEWER-SANITARY-STDate Repel I#(Thlsacction need nut becompleted Ifthe permit b for onehundred dollars P(f100)mIcas.) WATER fY/vENERGYFTE Y ' ' N
I codifythat in the performance of Uiewrrk for which this permit le issued,I shall not employ any person In any manner so m to become subject to the WATER SYSTGI/TRFWorkersCompensation Lawsof Califomla.Date PAIDaP Q Date Recei t#
A licantZ O NOTICE TO APPLICANT.If,after makleg this Certificate of Exemption,you NEW RESIDENTIAL PL
1" should become subject to the Workers'Compereation provisions of the Labor ,. TOTAL:
W Code,you=at forthwith comply with such provisions or this permit shall beTAL: O
] deemed revoked. B (:FEE
r
CONSTRUCTION'LENDING AGENCY SEISMIC FEE 0.22.
tl O Ihereby afflrentlut them b a comtruction lending agency for the perform
—
0 - ELECTRIC IEE
/
Z anreoftheworkforwhkhthlaperMtbIssued TOS.fl X07
U 1<nder'sNann PLUMRINGFEE
LL F Lendeea Addreas QTY. MECHANICAL PERMIT` FEE. MECHANICALFEE
OW . lcenifythatlhavercadthiasppllcationandstatethattheaboveinforrwtirn ,- —
C iscorred.7 agree to comply with all dtyand county ordinances and elate laws PERMI'IISSUANCE / FEES PAID:
>. relating to building construction,and herebyaubmixe repreeentatives rfthls
Zcity to enter upon the above-memioned property for ImpeoBon purposes. ALTER ORADD'TO MECH.
_ (We)agree to save,indemnify an d keep harMem the City of Cupertbw - Date Recei t#
against liabilities,jr dgments,exanand expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
st said Gtyin ronerquena o(t antln of this permit../ AIRHANDLINGUNIT(OVERID,OIOCFM) CONSTRUCTION TAX
-weeaf Apffiant/C�n�r Datil— EXHAUs'r HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappnant orfuturebWldingoavpam store or handle hazardous HEATINGUMTITO ioilo1 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BM TOTAL: 7
❑Yen No ,
Will theapplimm or fu turn building occupant useequlpmcnt ordevices VENRIATION PAN 61NGLE RFSID)' - ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OFR'OR 100,000 BTU) v�a gpay'1
•, 4
Yea QNo
havercad Healthe h
ara"fet materials tions 25505,25533 and
6.95 of BOILER-COMP(OVER I W,000 BTU).
the CziiforNa Heahhk5afety Code, otcurrntlyh have
and 25534. 1 O t
reeponunderatendthmn tIfyhe the ing occupant not a mqu ImmortalemhL that It is mybe NEW RESIDENTIAL MECH. SQ.Ff. y+ y fa 1 1
respomlblllly to natty the occupant of the mqulrcmenb which must he met � — 4.h•�t
prior to Jesus nee of a Certificate of Omapsmy. pltj1111
Df�r11 �� y.�c
Owner or authorized agent Date 1SSI11eD BY: PK-*-•'�•�s•
TOTAL:
OFFICE COPY