19533 {dPPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
iolldfng Add...ildloru'en Identification _ PERMIT N0.19533
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ams CITY OF CUPERTINO-BUILDING DIVISION
C°^ °�•N Lic.No- APPLICATION / PERMIT — — qU
Ask eRkal BUILDING-ELECTRICALML GING-MECHANICAL CATEGORY CONTROLqW
Architect/En neer. s Lle o:
QTY ELECTR/CPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE � 1:1 11 11LICENSED CONTRAROR'S DECLARATION
I hereby effirmon7E that 0Bof Dn licensedA3 ofthnderinessaonsol Chapter9(comndmy APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith5enlon 7000)of Dlvibn 3ollhe Busirmssand Profesalona Code,and my s
licenx le In tuBf 9nd erten. PANELS
Llm. CWAs Lie.A 3 s e if vv" C v
Dale onmtch-rUP TO 200AMN
ARCHITECPS DECLARATION 201-IOW AMPS
aO Zp I understand my plans shall be used as public records JOVERIODDAMPS SQ.IT.FLOOR AREA f/SQ.FT.
�j Licensed Professional SIGNS ELECTRICAL
lLRi1 OWNER-BUILDER DECLARATION
bi
7l, Thereby affirm charism m
ezeptfromthe Conlractofs Lkense Law loathe SPECIALCIRCUIT/MISC
qqqq following reason.(Section70315,Businessand Pmfeesluns Code:Mycity,or
F t'q county which requires•permit to construct,alter,improve,demolish,or repair 7TR.IP.METQi ORIOLE INST.
`'0 3 any stmetum prior to its Issuance,also requires the applicant for•ich perret to
file A signed Nahm,at that he is licensed pursuant to the provisions of the ]OWER DEVICES
3u. Contractor'sLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING FOOL ELECTRIC
ti�Os sion3aflhe Business and ProfemiomCode)orthat he W exempt therefmmand VALUATION
the basis for the alleged exemption. Any violation of Semon 70]1.5 by any • D D U
OS OUTLETSSWITCIiESFIXTIIRES
appRwnt for a permit subjectathe applicanito a civil penalty of not..the.
five hundred dollars , - NEWRFSIDENTIALELECIR SQ STORIES TYT'ECONSTRUCTION
�n ❑Las owner of theheproperty,or my employees with wages thele sole
compensation,wllldothe work andthe atmcturc W not intended or offered for
O •ale(Sec.7ply Buainessandf pmpelry Cade:The orimpnces LlemeLaw
whorl lapchy rkht nlorth=gtywhonempoyen,p eidh thgand OCC.CROUP RFS.UNRS
wprovementsann tIntendedcrwghhlsowale.1( oweprovidedthatevth
improvementsarcnot Intended earofco pletioe.Ir,however,theerlldl have TOTAL:
i ImprovementWwld within oneyearo/compinlon,rhe owner-bullderwlll have
t Aden of proving that he did not build or impmve for purpose or sale.). QTY, PL BINGP IT FLOOD ZONE APN
LJ L a•owner of the property,am exclusively contracting with licensed PERMR ISSUA CE
commndea to ronstmct the project(Sec.7096,Buslnem and Pmfeasiom Code:
The Contmdorb License Taw does not apply to An owner of pmpe rty who ALTER-DRAIN
Wilds or improves thereon,and who contracts for such p(ojdxs with A -
g5actor(s)licensed pursuant to the Contractor's License Law. BACK EL FEE T T. 7 FEE SUMMARY
c L�I am exempt under&c B &P C for this..A
Owner Date DRAINS 77.00 R F,A SANITARY Y N
RECEIPT N
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N
11(1 hereby affirmthat I have a certificate of consent mself-Insure,or a 7TXTURE4 PER
n Imre of Wo n'C perualloolmurantt certifi ro lharmf(Sec. RECEIPT
CAS EA.SYSITM-I INCA OUTLETS
3800,[ab CJ I/tee ,j/y^ ) P}],�]
PARK PDT Y N
/ (a-Ty) RECEE'fN
CAS EA.SYSTEM-OVER 4(EA)
any BUILDING DIVISION FEES
m Cenlfled copy is hereby fiafiled
the city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE /Z
CertBled ropy W(fled with the city lre)aenlon division.
CERTIFICATE OF EXEM PFION FROM WOR KERS' CREASE'TRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200IT. Date Remi t#
(Thisacnion need cid be completed lithe permit W forone hundred dollam
(. Icerrfem.) WATER HEATER W/VENT/ELECHt ENERGYFEE Y N
I mnotfify that employ
an perlme In any m work for wto cern•permit ct blued,
Whell not employ any demo^In any manner ao u to become subject to the WATERSYSTEM/TTEAUNG
' Workers'Compensatlon[..of GIIlornW. Date PAID
-
Z Z Applicant NEW RESIDENTIAL PIMB. SOFT. ,Date RCCeI t#
Z O NODCETO APPLICANT:K,after making this Certificated/Exemption,you
should become subject to the Workm'Compensation pnevleiom of the Labor TOTAL:
~ U) Cade,you most forthwith comply with.uch provlaloco rthis perrAt.hall be
W > deemed revoked. BUILDING FZ.�`Z UO
WEE
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of@m that there W a conatmedon lending agency/or the perform ELECTRIC FEE
Z ante ofthe work for which this permit l•Issued(Sec.3097,Civ.Q TOTAL:
U O Lender'.Name PLUMBING FEE
IL I— Lender's Address QTY. MECHANICAL PERMIT ' 'FEE MECHANICAL FEE
O W Icertify that l have mad this appliatbnand state thattheabove id..tion
b correct.I agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID: V
>- N relating to building comtmetion,and hereby authorize representatives olthis (_23* �31
Z city to enter upon theabove-mentloned property for inspection purposes. ALTER OR ADD TO MECH.
(We)agme to save,Indemnify an d keep harmiess the City o/Cupertlno Date. Receipt#
V against hablBiles,judgments,costs and expenses which may In anywayaccrue AIR HANDLING UNIT(TO t0,0D0CPM) SUBTOTAL'
Against said City In consequence of the granting of this permit.
ALR HANDLING UNIT(OVER ta,00o CFM) CONSTRUCTION TAX
Signazureof Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or/utum building occupant storeor handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Ir.1th and Safety Code Section 25S32(a)7 HEATING UNIT(OVER 100,00)BTU) TOTAL: 67,TV
Fly. fel No
Will the applicant or tore building occupant use equlpment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air centarWeants as defined by the Bay Area Air "
Quality Management Dimt-let?. BOILER-COMP(3HP OR 100,0()0 BTU) 9
4Yes ❑No / T '9—16 0
haveread theth&Sfet Code,brcom 255nbunder Chapte4.1 of BOdFR-COMP(OVQt 100,100 BTU)
(M1e GlEornW Health&Safety Code,Section 75505,15533 and 25534.I
understand that if the building does not currently havealenanq that it le my NEW RESIDENTIAL MECH. SQ.FT.
responal6Bity to notify the occupant of the requim Amts which must be and
PH to canes Ce 10 of
V
Own raulhoriud agent Baer ISSUE
DO
TOTAL:
OFFICE COPY