19816 LICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prosed Identification PERMIT NO.
,ullding Address:�`�1s �� gwo _ 19816
1> Iu1W IV ' 7 S 1 Phone: A
ld
Z�$''2L7$ CITY OFCUPERTINOBUILDINCDIVISION 2
. co^((ra^te:•Na^,e, C ue.No APPLICATION / PERMIT
.meg= 7151,5 S`a Z4S� BUILDING-D.ECTRICALPLUMBINGMECt41NICAL CATEGORY CONTROI,N
Amhitect/Engineer. Lie.No:
.g1ti „ELECTRIC PERMTT ^IgE BUILDING PERMIT INFO
Address PERMITISSUANCE /,� ❑ Y� [:1 ED CONTRACTOR'S DECLARATION
I herebyaffirmthat l amlicensed under provisions of Chapter 9 immanent, APPLIANCFSRESIDENIIAL JOB DESCRIPTION
Ingwllh Sedlon7000)of Divlsion3ofthe Businessand PmfesionsCode,and -
licenselein(ull and effect. PANELS
License Ckss_�Lk.N Contract SS
Date�'_j`aI�_ HITE1 Vel
ARCHall ECLARATION OVER 00AMI5
QZ !understand my pUmshelbe used epublic nroords OVER 1030 AMTS SQ.Fr.FLOOR AREA S/SQ.FT.
O
dF Licensed Professional SIGNSELECTRICAL
n I
6 OWNER-BUILDER DECLARATION '7
!n`] SI'ECLIL CIEtCNi/MISC Z ,~
7F,"J, owing affirm Secti.that I 7MIS,exempt fmmthe d Pinfesdo .Coca:Gw fort he
pp following calon70 w Business and Pro pmvc e=le hey mpair
O Z t-.� TEMP.MF.T[ROR POLE INST.
or
K� Ceunlycture requlrosa pormke,also quiresthedalte� applicant
for.bh,ormitto
g any stmaure priortostatement
its that
he,Is licensed peahen to
p nuchpermlt a ppkygR DEVICES
file a signed statement that he k licensed pursuant to the provblore of the
W6 3 y, Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
H�O� eton3oftheBuslnessandProfmd,usCod,,)orthatbeisexempttherefromand VALUATION
_ the basis for the alleged exemption. Any violation affection 7031.5 by any OUILETSSWITCIiPSFIXTURES
Q� applicant fora permit subjedsthe applicant toe civil penalty of no[morethan
Q flue undyed dollars(¢500).
u. ,,__....JJ++
�n L_Jl,as owner of the property,or my employees with wages utheir sok NEW RESIDENTIAL ELECTR SQ'FT' STORIES TYPE CONSTRUCTION
C compensation,will d o the work and the structure Is not Intended or offered for ` T'V__� C F1 TO_1W
5 O sale(Sec.7064,Business and Professloru Code:The Contractors License Law
[j 2 docs not apply to an owner of proerty pwho builds or improves thereat,and OCC.CROUP RES.UNITS
0.0. who does such work himselforthrough his own employee,provided that such
improvements are not intended oroffered forsaie.If,however thebullding er TOTAL:
Improvement bsoid within ooeyearofcompimiogtheowner-budderwill have
t11RlZurden of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE FFOOD7DNE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7W4,Rusinessand Pnefesslons Code:
The Contractors License law does not apply to an owner of property,who ALTER-DRAIN k VEM-WATER(EA)
bunds or Improve thereon,and who conmen, for such p(ojeats with a
c5actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B &P C for this reason
DRAT SFLOO ROOF, SANITARY Y N�
vEES
Owner - Date R AREA,GOND. ".) RECETTN
WORKMAN COMPENSATION DECLARATION FIX PER TRAP I SCI OOLOOL TA�—N_
❑I hereby affirm that I have a certificate of,consent to self-insure,or a 1 RECEIPT N
Cediflnteof Worken'CompemaHonlmunnmora certlfind copythereof(Sec' _G SEA. $TEMI INCA
3800,Lab C.) PARK FEE Y N
Policy x - I RECEIPT M
Com any, _N bLJ^a.4V'r G EA.S OVER4(EA BUILDING DI VISIONFEES
Certified copy ishereby lunnnhed.
certmedcopyknkdwithtbeatytntpeM odivTalon. a se/INDflfgjyd�ynsre P NCF-IECKFEE
CERTIFICATEOFE'%EMPEION FROM WORKERS' GREA PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EIBOFT. DRccci
(This section need not be completed If the permit Is for one hundred dollars A. ate Pt#
(s100)or rase.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertl/ylhat in the performance ofthe work forwhlch this permit is Issued, —
1 shall not employ any person in any manner so as to become subject to the WATER gYSTCM/TRGTING
Workerv'Compensatlon Laws o(Gllfornla.Date PAID
C• Z AppliNOTICE
NEW RESIDENTIAL PLMB. SQ.FI'. Date Recti t#
Z O Nould become
APPLICANT:totheWork makinWorkers'
thin
tationlnteof Exemption,you
sowed berona subject to the Woofers'much p r provisions
previsionsof the Labor TOTAL:
I� >
Code,dnw.etforthwith comply with much provislona oriole pemJt hall be �� FEE
� j deemed revoked.
dC CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
7 Z ante ofthe work forwhlch this permit is Wued(Sec.3097,CIv.C.) TOTAL:
U O Lender.Name PLUMBING FEE
IL 1 Lender.Address QTY. MECHANICAL PERMIT FGE MECHANICAL FEE
O W IcertilythatI have read thlsappiiotlonand date that theabdve infomation
(Seemed.I agreeto complywithall city and countyomlinances and date paws PERMIT ISSUANCE FEES PAID: -
CL relating to building construction,and hereby authorize representatives ofthis
I_ N city to enter upon the above-mentioned property for Inspection purpose. ALTERORADDTOMECH.
Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recei t#
V agalImt liabilities,judgment.,codsand expenses which may litany wayacerue AIR HANDLING UNIT(DO 10,000 CPM)) SUBTOTAL:
mgalnstsald City i^cansemi enreofthe grentingo(thie permit. -
AIR HANDLING UNIT(OVER 10,OmCLM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUS'11IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO ID0p00 BTU) Date RCCej 1#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Iiealthand Sa CCot,eniors 75537(.)7 HEATING UNIT(OVER 100,"BTU) TOTAL:
E] Yes . CJ No'
Wllltheappilnnt orfuwre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUAI`�Ey�7•(E
which emit hanrdous air contaminants a.&flrW by the Bay Arca A1, 4—.,�f��T
Quality Man t Mat BOR.F.R-COMP OIIP OR 100,0(10 BTI!) A'a!'i
❑Ye No
- - phave read the h & ou.materl Sail. immenta under Chapter 6.95 of BOILER-COMP(OVQt 100,0008111) ^ '7 )
i the Gll(omla Health&Safety Code,Senlons 755!15,25533 and 75534.1 • '-�` 1� s
understand that lithe building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQA7. (
responsibility to notify the occupant of the requirements which must be met Cid!Of aa_
rlor to Issuance oft Certificate of Oc ang% 5r, -y NJ1�
�- -3
_ n car aulhorlud agentI Dae T
TOTAL: ISSUED BY:
OFFICE COPY