19326 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO,
BuiEd'nq Adders°:Osr-oo 19326
n rPho e: A
. h:� CITY OF CUPERTINQBUILDING DIVISION
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der's Na x: — LIe.N.: APPLICATION / PERMIT
BUILDINGELECTRICALPLU3MBING-MEGFtANICAL CATEGORY CONTROLNS—,Z
A h
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adderes: ' PERMITISSUANCET;Zjn r171
ICN SED CONTRACTOR'S DECLARATION µ� y�
I hereby afforothal l amllcrosed under provisions of Chapler9(commmc- APPUANCESRESIDENTIAL JOB DESCRI'HON
ingwith Section 7000)of Mvision3oflhe Businessand PmfesslmsCode,and my
Ti«nne Islamiforte and effect PANELS
Limnse Clam Lk.M Q 1`
Dale Contractor k
ARCHITECPS DECLARATION 201-IODDAMPS
�7 I understand my plansshallW used as pubbcrccords. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Z�j Licensed PMcalonal SIGNS ELECTRICAL
�¢FA to OWNER-BUILDER DECLARATION SPECWLCIRCUIT/MISC
i.., I Iherebyafflrm that l am exempt from the Contractors License Law for the
709_ following reason.tSealon 70315,Business and Profneslons Code:Any city or 3FMP,MET[R ORIOLE INSt.
Pmcounty which requires a permit reconstruct,alter,improve,demolish,orespalr
Q.a any structure Inform its Issuance,she requires theapplicant forsuch permit to POWER DEVICES
a V file a signed statement that he is Brensed pursuant to the provetions of the `
Owl, Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOL E
30 sion3ofthe Business andPMevlonsCode)orlhat heb exempt therefromand VALUATION O
g 6 5 the bash for the alleged exemption. Any violation of Section 70315 by any O E'ISSWI Fl%7l1RES /�D O
O applicantforapermitsubjectstheapplicanttoacivilpenaltyofnotrrorethan a '0 p�oD
five hundred dollars(S500). NE RESPATIAL ELECTR SQ.FT. STORIES 3YPECONS'IRUCHON
❑1,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure b not Intended or offered for
Osale(Sec.7044 Business and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilds or improve.theme,a OCC.GROUT' RIS.UNH'S
E whodonauchwork hlmrelforlhreugh hisoweemployers,provided that such
improvemenlsarc not Intended oro(fered for sale.If,howeveq building or TOTAL: aQ
impressment bsold within oneyetrofcomplellon,Ihcow ,% Id rwlll have eL
mbr,Qurdenof pervingthal hc did not Wildorimpmve for pu orale.. UM ING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,to exduaively mraot.Ing It Ilor ISSUANC
..i.e.to construct the project(Sec.7044,BusInev and Prole 2xen
The Contractor's License Law does not apply to m owner of p o L -D - IN - A (G)
Wilds or Improves thereon, and who contram for such ptoje- Ith a FEE SUMMARY
actor(sHicensed punuant to the Comractor's License Law.
IJ I am exempt under Sec- B&P C for BA DZ DEVICE k� OUTSI13C FEES
n DRAT OOF,AREA,COND. SANITARY Y_ N_
Omer Dale RECEIPT p
WORKMAN COMPENSATION DECLARATION F7X SCI100L TAX Y_ N_
❑I hereby orf m that 1 have a i certificate of consent to opytnsurv,ora RECEIPT Y
certif38W,izb of Workers'Compensatlon Insurance oracertifled ropythemof(Sec. G G. STQ.4I INCAOUTILETS PARKFEE Y N
3800,lab CJ RECEIT 0
policy It GAS EA.S S EM-OVER 4(EA) BUILDING DIVISION FEES
Com any
�Certifled ropy E hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
.�CenlOed copy I,filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID_11-22:942L73 yy _
COMPENSATION INSURANCESEWER-SANTARY-STORM EA.20()FT. Dale Rceci IN
(this section need not M completed If the permit b,for one hundred dollars
($100)orless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that N the performance of the work for which this permit is Bard,
I shall not employ any person In any manner se as to become abject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Calirorola. Date PAID
OZ Applicant Date Recei t#
Z NOUCETO APPLICANT:ILafter making this Cen0lcate of Exemption,you N`EW RESIDENTIAL PLMB. SQ.FT.
POshould become subjaY to the Workers'Compensation provisions of the Labor t� TOTAL:
N Code,you must forthwith comply with such provommorthis permit shall be Z, f BUILDING FEE •SO
W >
charmed revoked. PP �-� �� C-V SEISMIC FEE
CONSTRUCTION LENDING AGENCY t I ix
d 'hereby affirm
.,kf.rwh1hhe late mo ktbas lending agency for the perlorm- TOTAL: ELECTRIC FEE Oi00
Z anree(the workforwldch this permit is issued(Sec.3097,CIv.C.) 20s� PLUMBING FEE A
Information
LL O Lender's Name
W U lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FBG
U Irerd.Ia agree haveto
mplywthaead this llcityndcou and tyordi nabs and Mate
FEES PAID:
O IL ismired.building complywo,all heredcountyoedmanm and etatehws PERMIT ISSUANCE CD
in 1 reytoentering to ulldingconsWalogandherebyrty fee
epectioenpurpoa of this
cit Neater nthc,indemnify an
forW Ion ALTER OR ADDTO MECH. Date Recei t#
F Z Y °P° P'°Perh' PM puryoses.
(We)agree to save,Indemnity and keep harmless the In a of Cu accrue AIR HANDLING UNIT(IO 10,030 CFM) SUBTOTAL:
U against liabilities,7adgmenls,costa end expenses vhich may In anyway accrue
I reRod Cityick granting this permit. CONSTRUCTION TAX
AIR tiANDW NG I3IJIT OVER t0,000CIM)
Slgw fAppl cant Contractor Dam EXHAUST HOOD(W/DUJCT) I 1SQ CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hamrdous HEATING UNIT(M 100,000 BTU) Date Reuel t#
material as defined by,the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safely Code Section 25532(,)7 HEATING UNIT IW,OW BTU) 1,:
se�pI�Yes �]No
''SvilI the applicant or(uture building occupant use equipment or devices VFNILATION FAN(SINGLE RESID) ISS A ATE
which colt havrdous air contamimnt.as defined by the Bay Area Air
• �ityManagementDistrict7 BORER-COMPpi-0'OR100,000BTIn f wi3 141990
Ya No
have read the h. oua male,lab erqulerments under Chapter 6.95 of IiOILER.CONP(OVER 100,000 BTU)
the Glifernla Health&Safety Code,Stolons 25505,2593 and 25534. 1 piss rITP w
understand that if the building does not cu it havcannant,thatitiamy NEW RESIDENTIAL MECH. SQ.Ft. asµ) r
r¢ponsibilitymndifylhc..pantofthe requ' ex which must be rect
'lir nuance of"'ofOancy.
`t
a Dale I ISSUED BY:
TOTAL:
OFFICE COPY