19489 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification /� //�' � n/, PERMIT NO.
IBuRding Add.,,: P� J////!1 (�/f e I z— —� 19489
06 V p'hhone: A A A
1 1Y—JS T uA9Q, d57-ZPF/3I CITY OF CUPERTINOBUILDING DIVISION
cant �Aas � •� /� 6 APPLICATION /PERMIT 2� Q•(3
7 BU[LDINGELECTRICALPLUMBINGMECH LAICAL CATEGORY CONTROL p
Architect/Engineer. 0Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that l licensed order pron,calon.of Chapter9APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
IngwlthSecticox 7000)ot DivWon3oftlleBuslnvand'relead...Code,andmy
licensebIn fu d c, `if/(/v_S C/� PANELS
Liwn'•y UP TO 200AMI5
�Lic.p ",1
Date Contractor GGLL 2011000 AMPS
ARCHITEe use DECLARATION
07. lunderstand my piawahaB be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
ww O Licensed Professional SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION SPECNLCIRCU1T/ LSC
L, Z Ihercbyaffirethat l amexemptfromthe Contractor's License law forthe
O F. following reason.(Section 7031.5,Rustiness and Professions Code:Any city or TEMP.METER POLE INF. ' 1
y county which requires a permit to construct,alter,improve,demolish,or repair U
anystmc mprlortoltaL ance,alwrequimtheappliantfwsuch perMtto ppWERD CFS
UfiM a signed statement that he b licensed pursuant to the provisiore of the
Contractor's License Law(Chapter 9(commencingwith Section7000)o`2o
Di vi- G LELECfRI VALUATION
slon3ofthe Business end ProteslomCode)orthat hebexempttherc(romand
'St < the basis for the alleged exemption. Any violation of Sectloa 70315 by any O ETSSWI H ES
appilcant fora permit subject/the applicant Ina civil penalty of not marc than
F Ove hundred dollars he pr). NEW RESIDENT] }7, STORIES TYPE CONSTRUCTION
I,as owner of the property, l my employes with wages r thele dole
uars
compensation,KBusiness and kfeasio stwcte:TheC ntract r'orcanse Laorw
❑ sole(Sec.70K to an owner
df property
who builds
Compoves Lremn law
{2j5$
does not applytoanownerofpmpertywhonemporimproovided thereon,and OCC.GROUP RFS.UNITS
CC wprovements am khimsededoraughhlsow ate.Ify everthebuihatauch
Improvementsarenmintended earofrcdforsilo.((however, deer ill have TOTAL:
ImprovemenHs sold within oneycarotcrnnpletbry the owner-bu0derw111 have
to,q.J;uMen of pmvGg that he did net bund orbnprove far purpose ofsals.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE MINLJ L as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE
contrsctma to construct the project(Sec.7044,Business and Profacdo.Code:
The Contnctorb License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Improves thereon,and who contracts for such p(ojects with a
cgn4ador(d)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C far this reason BACK FLOW PROTECT.DEVICE
DRAINS FLDOR,ROOF,AREA,CO SANITARY Y_ N_
Owner Data RECEIPT p
WORKMAN COMPENSATION DECLARATION FIX'IVRFS PER TRAP SCIIODL TAX Y_ N_
❑I be
a(fbm that I have a certificate of consent to self-Inwrc,or RECEIPT If
certificate of Workers C.mpe®.tion Inourance or a certified copy themofi5ec. GAS EA.SYSTEM-1 INC UTLETS PARK FEE Y N
acyIf MQ--) 193q-j8 - RECEI7q
Cram nv ( GAS FA.SYSTFM-O 4(FA) BUILDING DIVISI ON FE ES
Lj Certified copy is hereby furnished. GREASE/INDU L WASTE INTERCEPTOR PLANCHECK FEE
14Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GCSE PAID
COMPENSATION INSURANCE SEWER. ARY-STORM EA.200FT. Date Remi t#
(Thissection need not he completed if the permit Is foram hundred dollars
($IW)orlcss.) WAT FIEATF72 W/VENT/EL[CTR ENERGY FEE Y_ N_
I certify that In the performance ofthe work forwhlch this permit Is lowed,
I shall nm employ any person In any manner soas to become abject to the W SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,.itsr making this Certificate of Exempt Ion,you
Hshould become subject to the Workns'Compensation provisions,of the Labor TOTAL:
W Code,you most forthwith comply with such provisions or thin permit shall be BUILDING FEE.
LU j deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
d IherebyafOrm that there b a corotroctlon lcndingagenry forthe perform TOTAL: ELECTRIC FEE
7 z once.fthew.rkf.rwhlchthbper tbbs C5ec.30W,Civ.C.I PLUMBING FEE
L) O Icnder'e Name
IL I— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 60
OW Icertifythatl have read this application and statethatthe above information
a Isarnect.l agree to comply with all city and county oMinancea and pate laws I PERM IT ISSUANCE -•� FEES PAID:
relating to building comtruction,and hereby authorlu representatives of this
W city to enter upon the above-mentioned property for Impaction purposes. ALTERORADDTOMECH.
Z Date Receipt#
(We)agree m ave,Indemnity an d keep harmles;which
the City of .pocmo
V agaWtlWbilltks,judgments,cons and expenses which rtay In anywayyyaccrue AIR HANDLING UNIT GO 10,00B CFM) SUBTOTAL:
.gairat al u saryence of the Parody of this Parm )
i' D AIR IiANDLING UTTC(OVER IO,000CFM) CONSTRUCTION TAX
Signature of AppUBianm(//CCcaarr.drr. I Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haraMous / HEATING UNIT(TO 100,ODO BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
1 lealth and Safety Code 5eclion2$532(a)2 HEATING UNIT(OVER If ,000 BTU) TOTAL: ♦Q�
❑Yes r]No ;�s
Will the applicant or futurebulldingompantux equipment or devices VENTILATION PAN TINGLE RESID) j$$U�AN. DATE
which
h et hazardous air contaminants as defined by the Bay Area Air
a1District? �a wftG�/t/��1
-IitYManagencnt ROII.FR-COMP PFN OR 100,0[0 BTU)
have read the h.-Z.u.materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Ulfarni.F1e.lth&SafetyCode,Sectlom 25505,25533.nd 25534. I
and soused that it the building does not currently have a tenant that It is my NEW RESIDENTIAL MLCFI. SQ.FT. 1A-
rsporaibll lty to not lfy the occtapant of the requirements which most be meetUna",
prior to issuance of a Certificate of Occupancy. r1�,`
10-/\A/
OwneroeauTOTAL thorizedagent Date O ISSUED BYNueii W`+"-
' :
OFFICE COPY