19337 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 19337
Phone: A A A
CITY OF CUPERTINO-BUILDING DIVISIONS--,-2,C �.
contra Draw `Lie.No: APPLICATION if PERMIT l
�) BUILDINGELECTRICAL-PLUMBINC-MECHAMCAL CATEGORY CONTROL# 57M
Architect/Engineer. Lle.No: ((��]1-�\
tIA '-I6 /✓ n L{ BUILDING PERMIT INFO
Gso S-LA, _C(AK Sk 1Q} QTY ELECTRIC PERMIT FEE
Acidness: PERMITISSUANCE 2-pV
LICENSED CONTRACTOR'S DECLARATION
[hereby affum that l am licensed under provisions of Chapter 9(commsc APPUANCESRFSPDENf1AL JOB DFSCREPTION
Ingwith Section 700()of Mvislon3ofthe Buslnessand ProfessionsCode,and my a�■
license I.I.full force andeffect. P A L E la/ 1 N ����
Date las. LIc.N
Date Contractor
ARCHITECFS DECLARATION 20I-1
OPre�O 1 understand my plans shall be used m public records OVER SQ.FT.MOOR AREA 5/SQ.FT.
L(�j Licensed Professional SIGNSEL /Qn/4 jfjTjft
C Z �—
< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/
f, 7 Iherebyaffirmthatlamexemptfromthe Contractors Licenselawfwthe p
7� following reason.(Setllon 70315,Business and Professions Code:Any city FR —7 or
O f-� TEMP.METIER OR POLE]NST. l
�p anystrcountywhirh requlresa perMtto she req iresthe applicant
for
ch,orrcpalr
G�ey�Q any.wcturepdorto its lsmrance,elao requirestheappllcam(w such permiuo POWER DEVICES
C 8 c.U file a signed statement that he la lirenaed pursuant to the provisions of the
Contractor's License Law(Cha er9(comrancin ithSection7000)ofDivi-
3 tc IJn B w SWIMMING POOL ELECTRICON
F O slon3olthe Businensand ProfessionsCode)ortFat M1ebexempt therc(romand 40
ES Ser S the W sl.for the alleged exemption. Any violation of Section 7031.5 by any
OQ OI77i'E'ISSWI7CI-1EZF7%7l1RFS
applicant fora permit subjects the applicant to a civil penalty ofnot mosubjectsW
! L
�.- five hundred dollars($500). NEW RESIDENTIAL ELECTR SQFT. STORIES I TYPECONSIRUCTION
I,as owner of the property,d my employes with wages r there sole
CZQ compensation,wWdo the ess and Professions
Code:
rcIs he ot IntendedContractor oroffered
w
' or
��O sale(Sec.TOSS Business and Professions Code:The Contractors License Law
�$$ does not apply to an owner of property who builds or improves thereon,and OCGGROUP RIS.UNITS
whodoessuchworkhimulf orthrough hisownemployees,provided that such
Improvements arc not intended oroffered for sale.If,however,thebuilding or TOTAL: S O
Improvement bsold within one yoarofcompletion the owner-bullderwill have
rdenof proving that he did nor build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD 7ONE APN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
traRors to construct the project(Sec.7016,Business and Professions Code: OO
The Contractors LImens,Law docs not apply to an owner of property who
builds or Improves thereon, and wha comram fee such projects with a ALTER-DRAIN&VENT-WATER(EA)
y5!Iactor(a)licensed pursuant to the Contractor'.License Law. FEE SUMMARY
L,I BACK FLOW PROTECTDEVICE
I am exempt under Sec. B&P C for this reason . FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�
Owner Date RECEIPT N
Em 4.MAl OMYBI NDECLA O. MTURES PER TRAP 'Z O SCI TAX Y N ac �^7-�l
[]T'f a �lrm that I have a certificate of consent to self-Insure,or a a R EIxT M l9 1 U
cenlflrat ( orkars'Compensatloninsurance ora rerti(led mpythereo((Sc<' GAS EA.SYSTEM-1 INCA OUTLETS `�� PARK FEE Y N
3�00,V CJ RECEIPT#
Policy# GAS EA.SYSTEM-OVER 6(FA)
Com any BUILDING DIVISION FEES
Certified copy U hereby famished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
F-lCwiified copy U filed with the city irapectlon division.
CERTIFICATE OF""PTION FROM WORKERS' GREASETRA P PAID if — 4h _T-32z s
COMPENSATION INSURANCE SEWER-SANUARY-SMRMEA 20OFT DateRCceipt#
(This section need not be completed If the permit U for one hundred dollars
($100)or less.) WATER HFATQi W/VFNf/ELECTR q eb ENERGY FEE Y_ N_
I certify that in the performance of the work for which this permit I.issued,
1 shall not employ an person In any manner.o s to be came bV to the WALTER SYSTEM/TREATING
Workeri Com ns n s (Gallo U.Date_4) PAID
O Applicant— 6 Date Recei tq
Z Exempt you NEW RFSIDENI3AL PLMB. SQ.FT.
Z O NO]ICETO ion provisions
r eo/onso Ion,
should become to the Workers'Compensatlone orthiansr it s Labbe TOTAL:
S y deen,yorrmn tforthwan comply with such provlamns or thin permit.naube ILDIN 'E
dxmed revoked.
lJJ ' CONSTRUCTION LENDING AGENCY SEISMIC FEE 1 - L
[L IhembyafOrmthat there U a construction lendingageory latrine perform- TOTAL: ELECTRIC FEE
:) Z ance ofrhe work mrwhichthl.permit U Issued(Sec.3097,CIv.C.) ` PLUMBING FEE
02 lender'.Name
F Lenders Addres. QTY.I MECHANICAL PERMIT FEE
00W
I certify that l have read this application and state that the above Information
Oordinances
77 MECHANICAL FEE
1 b correct l agree to comply with all city and county ordinancesER
and slate laws PERMIT ISSUANCE ( C. 0 FEES PAID:
>_ 0. ng to building construction,and hereby authorize representatives of this
I_ N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harmless the City of Cu portion Date Receipt#
V against liabilities,judgments,cans and expenses which may in any way accrue AIR HANDLING UNIT(TO 10.000 CFM) SUBTOTAL:
aga Wt said 5ity,incon ce of the granting of this permit.
ATR I-IANDLINC ITMT(OVER lO,WOCIM) CONSTRUCTION TAX
Signal Applicant/Conuactor Date EmAl15'T HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC SUR
WII a applicant or future building occupant store or handle hazardous HE
UMT(IO 100,030 BTU) L CIS Date RCCCI t(7
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I and Safely Code Section 25532(x)7 FIEATIIJG UMT(OVPR 100,000 BTU) TOTAL:
❑Ys No VENTILATION FAN RESID)
Will the applicant Futuro building occupant use equipment or devices Q (� ISSUANCE DATE
which emit hazandous air contaminants as defined by the Bay Area Air Quality ManagementDls et? BOILER-COMP OW OR 100,IX0 BTU)
No
4haveYcsread rhe Nazar Dues materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
r0It1e Califomla Health&Safety Coda SMlora25505,25533 and 25x536. 1
understand that lfthebulldlng dos not currently have atenant,that It U my NEW RESIDENTIAL MECO. SQ.FT.
respore iolity to notify the occupant of the requirements which must be met
Prior in lssu on
WsCertificamo(Om anry.
_ / #���
utM1orized agent to TOTAL: ISSUED BY-.
OFFICE COPY