19917 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: _ 19917
— / m•+�`/ hone: p
CITY OF CUPERTIN0.8UILDINC DIVISION
C° °or's� ' m LIallo, APPLICATION /PERMIT //G 15700
BUILDINGQ.WMCAL.PLUMBING-MEC}UMCAL CATEGORY CONTROL M
_ Arc Itc /Gglneer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE ❑ 1:1 El 11LICENSED CONTRACTOR'S DECLARATION
I berebyafflrmthat lam Bcensed under provbionsof Chapter9(exmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth5ection7000)ofDiNelon3 oflhe Buslnessand lsrofnalonsCode,and my
License Isle in onda ,,,�assa��'� PANELS `
Llrnnse has Lic.a
Date Contractor
ARCHITECTS DE LA�AIOITION �- 2014000 AMPS
q�q�uu m0 O I understand my plans shag be used as public records. OVER IOW AMPS �.FT.FLOOR AREA 5/SQ.FT.
E Licensed Professional SIGNS ELECTRICAL.
�«<< 'a OWNER-BUILDER DECLARATION SPFCIALCRCUIT/
2 E. +^ Ihercbyaffirm that am exempt from the Contractor's Llano law forthe
O F following mason.(Section 70715,Buslneu and Professions Code:Any city orMFITR OR E
county which requires a permit to construct,alter,Improve,derriollaM1,or repair
any structure prior to Its Issuance,also requires the appRant for such permit to 1`0 DEVIC
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)otDivl-
I,,,�OJ slop 3ofthe Business and PodrssbruCode)or that he b exempt therefromand SWIMQVG LQ- VALUATION
x....7777
the basis for the alleged exemption. Any ttoviolation civi of nakSection ect by any O� /��
app8ont fora permit subjects the applicant to a civil penalty of not more tion
five hundred dollars(¢500). NEW RESIDENTIA ELECTR SQ.FT.
I,as owner of the property,or my employees with wages as their sok STORIES RUC
CONSTTION
7114
c mpensatloo,will do the work and the structure is not intended or offered for
vie(Sec 7014,Boatman,and Professions Code:The Contractor's Liceme law
$ does not apply to anowner of property who builds or improves thereon,and OCC.GROUP RES.AMTS
whodoa m m
such work himself his own employers,provided that such
Improvements are not Intended oroffered forsaLe.If,hmveveq thebullding or TOTAL:
Improvement la sold within one yea rof completion,the owner-builderwlll have
tle�iurelen of proving that he dol n°t build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
L j L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCE
detractors to construct the pmjM(Sec,70K Business and Professions Code:
The ContrectarL License Law does not apply to an owner of property who ALTER-DRAIN k VENT-
WATER(EA)
Wilde or Improves thereon, and who contracts (a such plopcts with a FEE SUMMARY
dqIR(+ctor exemped t
Seent.
the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. e&P C for thh mason
OUTSIDE
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RFCFR'TM
❑I hereby affirm that 1 have a artlficate of consent to self-insure,or FIXTURES PER TRAP SCIi00L FAX Y N
certltlat (Workers'Compertsatlonlrourantt ora ttrtl(kd copythereof5m. RECEIPT
3800,Lab ) 7 GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N_
1, r �` . RECRIFTa
Cc�anv GAS F.A.SYSTE4-OVER4(EA) BUILDING DIVISION FE ES
Certified co b re tumcity CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
C]Certified copy h filed with the tl!y inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWEILSANITARY•STORM EA.20017r. Date ReCCI t#
O'hlssectbn need not be completed ff the permit is for ane hundred dollars
(s10()orleas.) WATER HFATQ4 W/VENT/0,ECTR ENERGYFEE Y N
I
coin the pertormantt o(thc work forwhkh this pemUt is booed,
I shall not employ any pereon in any miner so as to becom subject to the WATER SYSTE.4/TREATING
W°rkers'Compensation Lawsof Cahfomla.Date PAID
licant
Z 0 NO77 ETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SOFT. DaIC Recei t#
should become subject to the Workare'Compensation provisions of the Labor TOTAL:
f4,
Code,you=at forthwith comply with such provisions or this permit shall be BU
W deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
ILDING FEE
CL Iherebyafflthat there is a mwtruction lending agency forthe perform. ELECTRIC FEE
Z anttofthe workfor which this permit b Issued(Sec.3097,Civ.Q TOTAL:
I) O Lenders Nam PLUMBING FEE
LL I— Lender's Addnres QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I.AifythatlMvereadthL.ppRationandatatethattheaboveinfomutlw
O,w is mmct.I agree to complywith all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
IL relating to building mrotruRlon,and hereby authorize representatives of this
f N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTOMECEI.
Z Date Recei t#
(WO)agree to save,indemits and keep harmless the in a of Cu Fedactino
V raga utllab City pdgmnte,costsand expense which may in anywayamue AIR FU3NDLINC UNIT(TO 10,000CFM) SUBTOTAL:
a rut Id City N rmt.oqtianxbrty gra it of thl It
a Q Qat AIR HANDLING UNIT(OVER 10,WOCFM) CONSTRUCTION TAX
Sig roof Applicant/Can an to EXHAUSUC
Tfi00D(W/DT) CONSTRUCTION TAX PAID:
HAZARDOU ATF.RIALSDISCLOSURE
ill the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei l#
mterlal as deOnM by/he Cupertino Munictpal Code,Chapter 9.17,and the -
I lealth and Safely Codec,glerf"2M33h)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes o
ill the applicant or Boom building occu pant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUA�NGE�VTE
which emit harandous air contaminants,as defined by the Bay Area Air 1'1
Quality Management Dlstrl BOILER-COMP DEIP OR I00,000 BTU)
❑Yes o
]have read the hazar nusmaterials requirements under Chapter 6.950( HOILER-COMP(OVE 1100,000RIU) P�^� U I�,:.3
the Catifornh Health k Safety Code,Secgom 75505,25533 and 75534. 1
un mtand that it the building does not currently have a tenant,that It 6 my NEW RESIDENTIAL MECH. SQ.rT
sspo Ibllllylonalfythe to(thercqulremnbwhlchm stbe t CIbJ Of CiihRtf1110
prior ksvanceofa 1 am,f racy.
14
nen or autho Imd agrrr
TOTAL: ISSUED B
OFFICE COPY