19642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro;ed Identification 1' `-� I1 r .PERMIT NO.
Building Addis Ov -, \ V .c��kT or
, 19642
S'd\vi��' D Se Gt Se �vLa7/
w ame: rover: CITY OF CUPERTINO-BUILDINGDIVISION/oCep
C?
cent dor'aName: f - Ur.No: APPLICATION /PERMIT 12---. l
t�� G7WVS .S///UO . BUILDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL N
ArcMnect/Engineer. - Lie.No
qTY ELECTRIC PERMIT :FEg , BUILDING PERMIT INFO
Adtlree.: PERMITISSUANCE V D a ❑ Ey ❑ ❑ "
LICENSEDCONTRACTOR'SunderDECns of ChON Lj}
I hth bdion7")olavisionseftheBuimmalonsof Cssions9(commrnc- APPUANCESRESIDENIIAL 'JOB DESCRE'TION
InenseiSection force
dision3ofthegusineasand ProfeselonsCode,and my - •.
license Is Ins force and died. PANUS •�� �,p
Licen ClaLk.p S/N- cc
1 - ' � Itll� POry,
Date 11—q'— O Contractor G. f '
ARCHITECTS DECLARATION • 201-1000AMPS
q�q�
vv reO Zp I understand my plans shall be used as public records. OVER IMO AMPS, SQ.FT.FLOOR AREA $/SQ.FT.
HE Licensed Professional SIGNS ELECTRICAL
<�6 OWNER-BUILDER DECLARATION' SPECIALCItCUIT/MLSC.
F, Iherebyaffirmthatlamexemptfmmthe Contrador'a License Lwfwthe
Zp"' following reason.(Section 7031.5,Business and Professions Code:Any city or
Ozf"qq con whichre 1 a ,mitthmmutmd,altegim demolish,orre air TEMP.METER ORIOLE INST.
p �y t qu res pe prove, p
q mm X33 any awdure statement
he he is also sed pursuant t the prosuch peof t e POWER DEVICES
k5[E file a signetl statement that he t r 9(cod pursuant it the tion 7000) of the
[Qy Elu,
Contractor's ofthe License Lw(ChaptergCommencingwithxempt7000)ofDivl-
O In SWIMMING POOL ELECTRIC
El sion3.(the Business and Iro(e®lore Code)or that heir exempttherefromand ALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHE&FIXT(JRES
O
applicant fees permit subjects the applicant to a civil penalty of net more than
five 1,as
drofthepre, NEW RESIDENTIAL ELECTR' SQ.PT, ORIES TYPECONSTRUCTION
ollars%SM.
❑I,as owner of the property,or my employes with wags as thele sole
compensation,wllldothe work and ions Code:
is not Intended or offered for
O sale(Sec.apply
toanow andf property Code The or Improves
Liethemoe Lw
3 whoa not apply to an owner of property who builds or Improves thereory and C.GRO RFS.UNITS
i who does such work himself wthramgh hisownempl.yeas,provided that such
Improvements are not Intended oroffered foraale.If,however,thebuilding or TOTAL: 1)
Improvementiesoldwithln 0neyearo(complctlorythe owner bullderwillhave
tl�karden of proving that he did not bund or improve fee purpose efsale.). Qjy, PlaUM1fINCr".PERMIT FF,E� NE APN
LJ 1,asowner of the property,am exclusively mntrading with--d PERMIT ISSUANCE O
commodore to onstoat the project(Sec.7M4,Business and Pr.feeslons Code:
The Contractor's License Lw does na apply to ae owner of property who
builds or Improves thereon,and who contracts for such projects with a ALTER-DRAIN&VENT-WATER MA)
cg18(ador(s)licensed pursuant to the Contactors License Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE OUTS I DE IT ES
®
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATIONDECLARATIONDECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have o I certificate ate of consent to pytheure,(sa RECEIPT'N
380ifiab of WOrkere'Cooper,satlhnlnsumna0racertifled mpythereof(Sec. 'GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy
Lb CJ
Polley N RECEIPT p
Com any GS EA.SYSTEM-OVER 4(EA)
BUILDING DIV]SION PEES
riffled copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PL.ANCHECKFEE
Certified copy b(lied withh the city impedlen division. - '
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE
(This section need not be completed lithe permit is forone hundred dollars SEWERSANITARY STORM EA.200FT. Date Recel t#
(8100)rtiENERGY FEE Y N
wor fytlemJ
I at In the pekce
orman .(the wort forwhich this permit to issued, WATER HEATER W/VENT/ELECTR
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workcri Compensation Laws of California. Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Daft Recel t#
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should became subject to the workers'Compensation provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions orthbs permit shall be '
j deemedreerked. BUILDING •E
LU LU CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC PEE
7 Z once of the workfor which this permit is Issued Cast.3097,Cle.G) TOTAL e1.00 -
V O Lenders Name PLUMBING FEE '
LL H Lender.Addre.s QTY.1 MECIIANICAL PERMIT , `;; '•FEE" r MECHANICAL FEE
OW ]artifylhat]have readtbIs application and statethattheabovetnformation
C isrorred.lagreetommplywlthall dtyand co.mycedlnances and statelawa PERMTTIS5UANCE FEESPAID:
} W relating to building constroctlon,and hereby authorize representatives oflhls - /�����/� 66
(- Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDIOMECH.
(We)agree to save,Indemnify an d keep baroness the City of Cupertlno Date Receipt#
V' against liabilities,judgments,mansard expenses which may In any way accrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
against Id Cltyinio one of the granting of this permit.
AIR HANDLING UNIT(OVER 10,M0 CIM) CONSTRUCTION TAX
Sigh res pp contractor T Date FXHAUSTHOODCW/DUCT) CONSTRUCTION TAX PAID:
N ZARDOUS MATERIALS DISCLOSURE
cap of orfumm building occupant store.,handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t#
material..defined by the Clopertino,Municipal Code,Chapter 9.12,and the
Ile,althand Safety Gds coon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: bt)
❑ Ye. Ln No
Willtheeppikantwf.mu building..pantuseequlpmentordevicos VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which rout hazanlous air co amiwnle ae defined by the Bay Area Air a-�
Quality Maogement Dist 7 BOILER-COMP OII'OR 100,000 BTU) Pa�L
4 Ves No
have read the baxa sus material.requirements under Chapter ISS of BOILER-COMP(OVER 1W UW BTU) _
the Califomla Health&Safety Code,Sections 25505,25533 and 25534.I I LIj U 199J,
understand that if the building does not currently have a tenant,that it is my NEWREMDFNIIALMECH. SQ.FT. ..
responsibility to notify the occupant of the requirements which must be met
prior to owuanc ff6 r ll.t., Occupancy. a
Own ro u agent Data -
TOTAL: ISSUED By
OFFICE COPY