19623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PE3LMIT NO.
Building Address: - 19623.
s ante: , vp-�S -0 Inure: A p
So Ag/ (,� CITY OF CUPERTIN0.BUILDING DIVISION �q Q
contrao mNa rc: Lm.N. APPLICATION I PERMIT C
C. oi . 5`-077Z BUILDING-ELECTRICALPLUMBING-MFGHANCAL CATEGORY 0(!M Aq
A6'LBGtT Engi r. Lift,N. J Y 7
St VA4S QTY ELECTRICPERMIT - FEE BUILDING PERMIT INFO
Aaarea.Po:goes, /,C yq- Cw-rnpGe.Ze.y qac PERMITISSUANCE 1•uL
LICENSED CONTRACTOR'S DECLARATION 9 ��/j�
'a
I hereby affirmthat l amheemsed under pemidonsof Chapter9(commenc- APPLIANCESRESIDENTUL JOB DFSCRIIMON
Ingwlth Sedion7000)o(D1Welon3ofthe Businessand Peefoxam sCods,and my
license Is In fu0 force and effect. PANELS
Llrense CWw Lica 'P19VI A /
Date Contractor e.y(l-(/� N"-,lT
ARCHITECTSDECLARATION XVE000A
q�q�uu ceOz lunders/and my plans shalbe used upubec records OVFRIWOAMPS SQ.FT.17.00R ARTA $/SQ.17.
E Licensed Profesalonal SIGNS ELECTRICAL
H Q E OWNER-BUILDER DECLARATION yT+ECIpLCIXCU[T/MISC —U U
7 t.., 2 Ihereby affirm that l am exempt fromthe Contractor'sLimmse law for the -
pp following reason.5extion 70715,Business artd Pm1.Ions Code:Any dty or
O F—H9 TEMP.MUM OR LE INST.
P� countywhichrequiresaper ttommtmd,altegimpmve,de=lbh,orrepair
q nystmcture prbrtoitsfevaance,han requlresthe apparent for much permit to POWER DEVICES
P Yd file a signed statement that he is lio med pursuant to the provisions of the
Q6 3 w Contractor's License Lew(Chapter 9(commencing with Section 7000)of Divl-
O(~n SWIMMING ELECTRIC
mIcOthe b sfthethealleedPrmfevbns CoyviolNon of exempt therefremany VALUATION O
5 the basis(cur the alleged exemption. Any violation of Stolon 7031.5 by any OUTLE TCHESFIX17URES 3 ��
applicant form permit subjects the applicant to a dvll penalty of not morethan �] a
five hundred dollars($.500), NEW R DENTIA].ELFGTRSQ.• STORIES TYPE CONSTRUCTION
7�m ❑1,as owner of the property,or my employees with wages as theirwle l
< compensation,willdothe work and thestmcture b not Intended or offered Wr-- Vr�p
O
to(Sc.7044,Rosiness and Professions Code:The Contractors License
L.,;'
does not apply to an owner of preperty who build.or Improves thermr4 and Teas
EEE whodoessuchworkhimselforthrough hiseememployees,provided thatsuch OCGGROUIs RES.UNITS
Improvements arc not intended oroffered forsale.If,however,the Z
buQd7ngor TOTAL: . 10
impmvementissoldwithinoneyearofcmmptdion theowner-bulldersJlU'ItavxO
ttwe,Lurdeo of proving that he did not build or improve for purpose ofs�i` Ty., IP&MBING PERMIT - FEE', FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting wiih Beensad" PERMIT DANCE
rontmMmtommtmdthepmjed(Sec.7016,Bulne dProfesslonsG e: - OL1
The Contractor'.Llceue Law dcea no apply to an o r of propertypRvho ALTER-D IN&VENT-WATER
builds or Improves thereon, and who rontacts for u pippetsfwith a �e •UV
co�B(Iador(s)Iimnwdpumamtothe Contndorn Lice L. a}lxJ BACK FLOW PROTFGT.D CE . .FEE SUMMARY
LJ I am exempt under Sec. _ B& C f, this reason hr FEES
m's4. Owner Data a l ({AINS FLOOR,ROOF, O SANITARY Y& NLUSID�
RECEIPT M
WORKMAN COMPENSATION DECLARA FIX7lJRFS PER (1
SCHOOL TAR Y N
❑I hereby afOrm that I have a rertNutc of consent t If-Inare,ora RECEIPT It
certi(kate olWorkers CompansaHonlnsuanre ora rertlfl c pytherrof(Sec. CAS P.A.SY5IEM- ]N O S PARK FEE Y N
3BOq lab C.)
Policy Y RECEIPT N
Com any GAS EA. 'O ER,;(EA) BUILDING DIVISION FF
Cv.fl rmpyishereby furnished. GRPASE/7N 11"
L ASTE INTERCEPTOR PLANCHBCK FEE
CertIOed copy b filed with the dty Inspection div Won.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASE7AA m I PAID_
COMPENSATION INSURANCE
(Thissedlonneed notbecompided Rthepermlt isforonshundred dollars SEWER.SAMTARY-STC EA.200FI'. Date CCC] t#
($10 mdifyss.) WATERHEATER W/VENT/ELECTR ENERGYFEE Y N_ �/1D
I certify that N the performance of the work(orwNch this permit is issued, ��('` J(/
I shall not employ any person In any manner m u to become subject to the WATER SYSTEM/TREATING �L D C
Workers'Compensation Laws of California.Date V PAID 8
O Z Applicant - NEW RE9D[NTIAL PLMB. SQ.FT. Date Re t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you (1
Hshould becomesub)ect to the Workers Compensation provisions ofthe Labor TO AL: Fu
y Code,you must forthwith comply with such provisions orchis permit shall he U IN 6.
> deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC
d G Iherebyafl hat there V a ronstmctlon lending agency for the perform ELECTRIC
Z anceofthe workforwhich this permit LsWaned(Sec.3097,Civ.C.) TOTAL: .oD ' a It
V O Lenders Noma � d PLUMBING F• _ d0
LLF Lenders Addmsa QTY. MECHANICAL PERMIT- FEE MECHANICAL PEE
O WIrcrtlfythatlhavemadthLappUmtionandpatethattheaboveinforrmlion - -
iscoreed.l agree to complywith all etyand county ordinances and date laws PERMIT ISSUANCE —Ui FEES PAID:
} C relating to building construction,and herebyauthoricampresentatives-this
HZ city to enter upon the above-rmendoned property for inspection purpose. ALTERORADDTOMMi. - V DatC ReC ' I#
V — (We)agree tm save,Indemnify an d kcep harmiem the City of Cu....Inca
galnst llablllE judgments,augaand expense which may In anywayemme AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTA
a sal By In ns the granting of1hb permit.
X l/Pyles^ /!/f�f/ vy�[�th AIR HANDLING UNIT(OVER 10,000CI:M) CONSTRUCTION TAX
( Stature.fApplicznt/actor ���K� Date EXHAUS'THOOD(W/DLKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occopant store or handle havardous REATINGUMT(T0100,0001ITU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the -
Health and Safety Codrerrr--S�ection 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
.❑Yes No
Will the applicant or f=m building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) rt ISSIay'.•Aj(IgT1A•1•E
�-- which cost haaardous air contardnenlm as defined by the Bay Area Air IL l"Y'1fT./-
i Quality Management District? BOfLFR-COMP C311POR 100,000 BTU)
n Yea n No
a �7(A �
` uve adtheha gusmte'HabrequlrementsunderChapter6.95of BOILER-COMP 100,000 BTU) JUN 1 I IM
he California Flealth&Safety Code,Sections 75505,75533 and 25534, 1
` 7, understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.17.
responsibility to notify the occupant of the requirements which must be and rat F, /Iu�..L.�
prior to issuance of a Certificate of Occupancy. '•Ir V rfi
Owner or authorised agent Date lJs ys�k✓C[�( j
'IUTA4 •SPU ISSUED RY:
OFFICE COPY