19488 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm4d identification PERMIT NO.
nu U38 Ra�e�vucL� der K�Z-a 19488
Z
m : phoe:s ,qhjVR-
CITY OF CUPERTINO-BUILDING DIVISION .� -2 t' b
cnn Nam: �1$N�6� APPLICATION I PERMIT � l
BIIILDINGFLECTRICALPLUMBING-MEC}IAMCAL CATEGORY CONTROL a
Archlted/Engineer. 0Lie.No:,
QTY ELECTRIC PERMIT, FEE BUILDING PERMIT INFO
Address: PM IITISSUANCE
LICENSED CONTRACTOR'S DECLARATION 1:1 11 X
I hereby afftrm that l am licensed under provisions ofChapter9(commmc APPLIANCFS.RESIDENfIAl JOB DESCRII'TION
ingwlth Sedfon7OW)ofDIVtston3ofth slneman (esslone Code,andm
license le lnf t ergnd d(eR. / 1 Z� PANES _
License Cla V Lic. ��
Date Contvdor
r14— UPTO2D0AMpS
ARCHITF.CI'S DECLARATION !�/TD OVER10 AMPS
p�p�uu aCu,
Z I understand my Flom shall W used m public records. OVER]Oo0 AMPS SQ.Ff.FLOOR AREA
k C Licensed Professional SIGNS ELECTRICAL A L E D
GG
Z. OWNER-BUILDER DECLARATION
G � exempt SECALCIC T/ SC !32V
7F, owingherebyrasormthatlam31.5,Business and
Contractor's Lirense law fort he G
pp following reason.(Section 7m1.5,Business and l'rofesslom Code:Any city or G
O y ti TE.RP.METER POLE INST.� muntywhich requimapenNt tocomtsuct,iltep bnprove,dennl6h,arrepalr 50
anystructure prior to lb Issuancealsorequires the appllcantforsuch permit to POWERD Ora
Ole a signed datemcnt that he V licensed pursuant m the provisions of the /'�
Q6 3 O Contractor's Llcerse Law(Chapter 9(commencing with Section 7000)of Dlvl- 10
SWIMMV(G A70L ELECTRIC
6
slon3oflhe Budneaand ProfesslomCode)orth thebexem theretromand VALUATION the basis for the alleged exemption. Any violation of Section by any O TSSWITCHESEXTURES
,pJ applicant for a permit subjects the applicant to a civil penalty of not more than
W � five hundred as owner ofthepars 0). NEW RFSIDFMiALELECTR,T_SQPT. STORIES 'IYPECONSTRUCTION
�n ❑I,as owner of the pthe roperty,and or my employees with wages as their sole
com(Sec.7on,Business
and rofesdhes Code:TheCare Contractors
orofferedfor
OIs(Sec.701q Business and Professions Code:The Contractors Llcenselaw
does not apply to an owner of property who Wilds or Improves thereon;and _
p who does such work him V orthmagh his own employees,provided that such OCC.GROUP RES.OIJI'TS
Improvements son not Intended or offered for sale.It,however,the building or TOTAL:
improvement is sold within one year of compidlon,the owner-buliderwill have
tYgIZarden of proving that he did not bund or Improve for purpose of sale.). QTy. .PLUMBING"PERMIT" FEE`' FLOOD ZpNE pppr
Lf L as owner of the property,am exclusively contracting wkh licensed PERMIT LSSUANCE
contradon to construct the project(See 7014,Business and Prof.(..Code:
The Contractor's Llmnm Law does not apply to an owner of property who FLYER-DRAIN k VFM-WATER(G)
Wilds or Improves thereon, and who contracts for such pto)ects with e
ryDI(actor(a)licensed pursuant to the Conmadorb License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec B k P C for this reason
Owner Data DRAINS FLOOR ROOF,A CSANITARY Y NOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION pD(TURES PER•IAAF SCHOOLTAX Y N
i, [31 hereby affbm that I have a ceninate of consent to self-Inasre,ora RECEIPT M
mdificateofWorkem'C_o/m/peens/atloalmuranceoracenifled[y��py thereot(Sce. GAS EA.SY5fEM-1 C.4OUTLETS PARK FEE" Y N
LBW,Lab C.) b2 J4"`�P—�9�l 61 1 p RIiCER'fq
Policy GAS. VEIR4(G)
Com anV .- BUILDING PTDIVISION FEES
Cenitled copy Is hereby my GREASE/IN SIRL WASTE INTERCEPTOR PLAN CI IECK FEE
CeniOed copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE S -SANITARY-SIORMEA 2ooFL• Date Recti t#
QN rIndian need not be completed I(the perrtdt V ionone hundred dollars
($RO fess.) ENERGY FEE Y N
I co"Ianity that in the pedomunce of the work for which this permit is w„ed, WATER HEATER W/VFM/ELGCIR — — .
1 shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING Worker Compensation Laws of California. Date PAID
—
Z Z Applicant NEW RESIDENTIAL PLMB. SQ.IrI'. Date Rece1 t#
O NOTICE TO APPLICANT:If,a Rer making this Cenifiats of Exemption,you
-
Hshould berame subject to the Workers Compensation provisions of the Labor TOTAL:
Ln Code,you=at forthwith comply with such provisions or this permit shall be _ IJILD
W > deemed revoked.
ING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL l hereby afnrm that there is a construction lending agency for the perform ELECTRIC FEE
M Z an.of the work for which this pemut b Issued(Set.3097,Civ.C.) TOTAL:
02 L.ender's Name PLUMBING FEE
IL I- lenders Address QTY. MECHANICAL PERMIT FEE. MECHANICAL FEE
O W l certitythatl have readthbapphotion and stam
tethat theabove inforation ��
1 is correct.l agree to comply with al dtyand county ordinances and state laws PERMITISSUANCE aa� -P) FEES
FEES PAID:
N relating to building construction,and hereby authorize representatives of this -
I— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,indemnify an d keep harmless the City of Cu Fortino Date Receipt#
again 11 illties,judgmertheaas expenseswhlch my inan ayaccme AIR HANDLING UNIT(TO 10,030 CFM) SUBTOTAL'
ugulm City In mnsryusnce a Ing crit I pe IL, AIR HANDLING UNIT(OVER 10,000 CITU CONSTRUCTION TAX
lit qs n z
Signature of Appllant/Contntt to I HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE'
Wllltheappliant or future building occupant store or handle hasardous HEATING UMT(TO 100,0006TU) Date Reeei t#
material as defined by the Cupertino Municipal Code Chapter 937,and the -
1{ea1th and Safety Code Section 25S32G)7 HEATING UNIT(OVER I W,000 BTU) vXOTAL:
OA M
❑ Yo M No
Wllltheappliant or future building occupant use equipment ordevucs VENTILATION PAN(SINGLE RESID) ISSUANCEDATE
which emit hasardom air contamirents as defined by the Bay Area Air --
`� Quality Maragement Distrfd7 BCBLER-COMP OHPOR 100,OID BTU) t v 1' �,j Ic
4Yes n❑No v J
havere.d the haz.Q .materials rect.herrnnts under Chapter 6.95 of BOILER-COMP(OVER 100,DOO BTU)
the Califomla Health&Safety Code,Sections 25505,25533 and 25534. I D
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MEC}1. S'Q.Ff. � (rt ,rJr)p,..FInR
responsibility to not lfy the occupant of the requirements which must be met r f
prior to I...race of a Certificate of Occup.ory. _^
Owner or authorized agent Date
TOTAL: ISSUED BY: L
OFFICE COPY