19933 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buimm Prom Identification PETLWTNO.
Building Add. 19933
IDT ��embe
wner phone: A A
ulanl�_ o2S7—<($73 CITY OF CUPERTINO-BUILDING DIVISION
&
cc.ntnLIc.No APPLICATION I PERMIT
( BUROINGELECTRICALPLIFMBING-METRO
CHAMCAL CATEGORY CONL N
Architect/Ggineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �V y ❑ - ❑
LICENSED CONTRACTOR'S DECLARATION L=P
Ihercbyaffurn that l am Bcensed under provislonsof Chapter9(commme. APPLIANCESRESIDENIAL JOB DFSCRI ON
Ing with Section 7000)of Etivislon 3 ofthe Business and ProfesslonsCode,and my
Datal9ln fu�j effect. / I'
Limns.Clam G�JCIC N_335�.(�N
Date 3—1 Co ARCHITECTS ARCHITECTS DCIA ATIO 201-1000 AMT'S
q 2 I understand my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
° u ALED IM
ti Z LI<chscd professional SIGNS ELECTRICAL
GG6 that
lam exempt
DECLARATION ��
I-n] hereby SPECIALClRCNT/MLSC
'G owingasormlbtlam exe5, fromBusiness
a Contractor's Code:
fort he
2 , following reason.Section 7031$Business and Professbns Code:Any city it
ER
F Icy countyanystm mprequires
ortoipermit
ancoawrud,equi theaplientfrsuch,erretto FOWEMETCRORPOLEIN a l3 O
mm 5 3 anya signercprlorrolre that
he gaLw reed Pursuant to
rovisiom of t e POWER DGVICFS T
ra IES Mile a signed statement that he is r 9(.m pursuant to the tion 7(om of the
o Cnntrador:License Law(Chapter 9(mmmendng with Section he()of Diel- VALUATION
FOS slon3ofthe Businessmd Pro(emlom Code)orthathebexempttherefmmand SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Stolon 70315 by any OUTLETSSWITCI-ffSFDTURFS O m
� appBantlora perMbubjeda the appilcanitoatlWl pevlty of not more than � 1
five hundred dollars(1500).�1,as owner of the property,or my employees with wages as their sole NEW RESIDENl]AL ELFCTR SQ. STORIES TYPE CONSTRIKT'ION
C compensation,will do the work and the structure is not Intended or offered for
5 sale(Sec 7044,Business and Professions Code:The Contractor's License Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.AMTS
who does such work himselforthrwgh his own employees,provided that such
improvemcroarenotlnmoded...Been]for sak.If,however,the building or TOTAL:
Improvement is sold within one yearofcompledor,the^wner-bu0derwill have 7
t rdenof pmvmgthat he did not build orlmprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contrading with Ilmnsed PERMIT ISSUANCE
metradon to mnstrud the project(Sec.7044,Business and Professions Code: Dew
The Contractors License I,aw don net apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA)
Wilds or Improves thereon, and who mntmds for such ptojectn with a
,➢I�&or(,)It...d pursuant to the Contradorl License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U 1 am exempt under Sex. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RFCEB'I=
WORKMAN COMPENSATIONDECLARATION _�A SQi00L TAX Y N
❑1 hereby affirm that I have ocertificateInsurance
c of consent to opfdnwre,or FIXTURES PER TRAP eco RECEB4 N
mrti(iate o(Worken'Compensatl.n lnsurana oraartlfled c.pythereof l5m. GAS FA.SYSTEM-1 INC4 OUTLETS PARK FEE Y N
3800,hb CJ
RECEIPT N
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Com an
` ,y ified copy 6 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city Inspection divismn.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA.2WFT. Date Rewi t#
(TMs section need net be completed lithe permit isfor one hundred dollars
(Slre)orlem.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I mmly that in the performance of the wok for which this permit is lowed,
I shag not employ any person 1n any manner so as to become subject to the WATQt SYSTEM/TREATING
Workcrs'CompcnsationU..fColiforms.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z O NOTICE TO APPLICANT:If,after nuking t his Certificate of Exemption,you
Fshould bemuse subject to the W.rkeri Compemat ion provisions of the Labor TOTAL:
CC U) Code,you must forthwith comply with such provisions or this permit shall be 13UILDING "E
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE 4
CL IherebyafOrm that them is a construction lending agency for the perform TOTAL: Q ELECTRICFF.E
M Z ante of the work which this permit is issued(Sec.3097,Civ.CJ
u2 fender's Name
L. - - TY. MECHANICAL PERMIT FEE PLUMBING FEE
1L f Lender'.Addmss Q MECHANICAL FEE
W isconIcertifythatlhavrmudi isapplicati ..rd statethatthe above Information
O
1 ect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r relating tobullding construdl.n,and hereby authorfee representativesofthis
rZ city to enter upon the abowmentioned preperty for inspection purposes. LTERORADDTOMECH.
(Wc)agree to ave,indemnify n d keep harmless the Cityof Cupe"ro Date Receipt#
U
against Babilitie pdgment,co and expenxs which may inanywayamme AI NDLING UNIT(C010,WCFM) SUBTOTAL:
against ealddd,,�..ity lrrr��ueeeppp000aasequen ofthe granting ofthlspemdt.
/Jl / /r ora � �> AIR HA DUNG UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signatu`m.f AppBaru/ o rano Date flfl EXHAUSTI D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthea applicant or future building occupant store or handle hazardous HEATING UM 100,000 Blip
PP 6 P Dale RCCCIpt#
material as defined by the Cupertino Municipal lCode,Chapter 9.]2,and the
ITeelthand Safety Code Section 75532(,)7 HEATING UN
(OV 1IX1,000 BTU) TOTAL: y.
Yes r]No
Will the applicant or future Wilding occupant use equipment..devices VENDLATION FAN(5IM1 ERESID) ISSUANCE DATE
which emit havrdous air contaminants as defined by tW Bay Arca Alr
Quality Management Dls 4 No BOILER-COMP BTU)Yes Fl No
have read the .osmate.' isrcqulrcments under Chapter 6.95 of BOILER-COMP(OVER lre,OreO a
the California Health&SafetyC 25505,25533 and 25534.1
understand that If the building d9¬ mrrently have a tenant,that it is my NEWRFSIDFNTIALMECH. .FT.
resporsibilitytondl the, mofthemllubementawMchmustbemH
prior/to�/span ( rtlf (Occupancy.
Owneiora h.rimd agent JLDate
TDFAL: ISSUED BY:
OFFICE COPY