20096 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification - PERMIT NO.
•. Building Address:,
'za6$ z s1n'fLdSfE
Mrs amc. one. A p
1 G�Q' a{F S I+YV CITY OF CUPERTINO-BUILDING DIVISION •, , ,I --.
canitadar.Name: - u=.N'la. APPLICATION /PERMIT f�R-1 L J 14 9
140
6-r QZ BUILDING-ELECTRICAL-PLUMBINGMECFIANICAL CATEGORY CONTROL Nsel S;
Architect/Engines 'Lie.Nese J I`�`
"i"' ° " :A,BUILDING PERMIT INFO; • •
• QTY ELECTRIC PERMTTI. l ? ,+,FCC',,
Address: - PERMITISSUANCEi.�
LICENSED CONTRACTOR'S DECLARATION - ,
Ihereby affirm that l am licensed under provisions;of Chapter 9(mmmenc APPLIANCFSRESIDENMI, JOB OESC 10
Ingwlth Section 7000)o(D%vision3ofthe Buslnewand ProfessionsCode,and my
iounse Iccma, In full force and c.N PANELS —)/— —/0,
/ -. /0 _l
License Claas iLlep N
Date Cantnctor
ARCHITECrSDECLARATION - 201-10DUAMPS
K Z I understand my phesshag be used as public remtds OVER 1000 AMPS - SQ.FT.FLOOR AREA f/SQ.FT.
qqµ�00 .
E
U t' Licensed professional SIGNS ELECTRICAL- �41 Z
d Q
OWNER-BUILDER DECLARATION ./�1 m t
In a SI'F.CIAL CIRCIfIT/MLSC , /�(f
7 T-'is owing r asormthat lam 31.5,B (messrom e d Professions
s torascCode;LawAny cl the
following reason.LSectlon 7031.5,Business and Professions Code:Any dty or
O i..(� TEMP.METER OR POLE INST.'
countywhkh requires oialssuanlo alsore uirestr,he aprovgdemolbh,uch Pennell
to
q any attudvre prtements that
he Is er and pursuant t the provisions
inionsf e POWER DMCLS - -
W4�"O.V Isle a signed statement that he is Ilmnsed pursuant to the proWsloM a( the
: , Contractor's License Law(Choper9(comn¢neingwith Section 7000)of DIA- VALUATIOI�L�
R.Os sion3Ofthe Businessand Pmfemiom Code)orthat he is exempt thercfromand SWIMMJNGPOOLELECTRIC rQn1 7-�^�, V=
6 X the basis for the alleged exemption. Any violation of Section 709L5 by any S OUILETSSWITCHFSFIXNRES , U q J U
applicant fora pernatsubjecfstheappllcamtoa doll pensity Ofnot morethan v 1
five hundred dollars($500).
I,as owner of the RFSIDENTIALELECIR SQ.FT. STORIES TYPECONSIRUCTION
property,or my employees with wages ant their sole
7a cempenaatlon,willdothewcekandthestrudurc knot intended or offered for
O saX,5.7' 14Businessand Professions Code:The Contractors License law
5$ does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RIS.UN
whodoessuchwork himself orthrough hisownempioyees,provided that such //
Improvemmnntsaromit intendedorofferedforsale.IQhmvever,thebuildingor TOTAL: ^a�
Improveent lsso)dwithin oMrarofcomplellogtheowner-bu'deiwlll have '
t rden of proving that he didnolbuild orimproveforpurpoeeafsale.).I OTY. PLUMBING PERMIT , FEE FLOOD ZONE APN
Lj L as Owner of the property,am exclusively contracting with licensed pNCE
contractors to construct the project(Sec.70x4,Busineasand Professions Code: U�
` 'Du•Contractor's Lime law does not apply to an owner ofproperly who
budds or Improves thereon,and who contract for such pkO)ecb with a ALTER-D ENT-WATER(EA) O
owam(s)licensed pursuant to the Contractor's Lice.Law. . 'FEE SUMMARY '
LJ I am exempt under Sea B &P C for this reason BACK FLOW PR C�nOUTS I DE FEESE
- DRAINS FLOOR,ROOF,A A, SANITARY Y N "
� Owner Date .RECEIPT#
r WORKMAN COMPENSATION DECLARATION FD(TURF_S PER TRAP Q SCHOOL TAX Y_ N_
Of hereby affirm that I have a certificate of consent to self-inure,or a O RFAF9T N
3800,cab Of Workeri COmpensatlonlnsuranm orarertl(Ied mpythercof(Sea GAS EA.SYSTEM-1 INCA 0UTLRTS PARK FEF. Y N '
3800.Lab C.) -
Policy N RECOPT N
GAS EA.SYSTEM-OVER 4(EA)
Cany BUILDING DIVISION FEES
omMCerllfied copy's hereby te
OCertlfled copy fit
GRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
' the city
inspection division.ry , 1 spy, [yip
CERTIFICATE OF EREMPTION FROM WORKERS' GREASE TRAP - PAIDL(4k*�a
COMPENSATION INSURANCE SEWER-SAMCARY-STORM EA b10FT Date Recd t#
(fhb sMion needn be completed
COMPENSATION
tbtoraM hundred dollare
($100)or leas.) ' " WATER HEATER W/VENT/E.ECTR C'NERGYFEE •Y N '
Icertify to 1 it r(Ornunceo(theworkfarwhkhth{e pe' la Wised,
I aha'nO[e i rears in any manner n a tphV6 the WA.fE!SYS.IFM/,ITiFA•(7NC
.WOFd
wsof Callfomia.Date PAIDL-t
O Z✓$ ApNEW RESIDENTIAL PLMB. SQ.F . Date ReceI t
_Z #O :[Lae fhb Certiflate o(Exemptlon,you
shog.•ct to rken'Compensatlon provisions Ofthe Labor TOTAL:
~ N CodthwIhmm withsuch bionsOrthb rNbhall be
LM j dee Py pros BUILDING FEE 3.O
U CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hembyaf((rm that there b a construction lendiagagenry farina perform
:) ELECTRIC FEE
Z ance of the work which this permit is LssuTOTAL:
ed(Sec.3097,Cly.C.) 00 ' T
V O Lender's Name k - PLUMBING FEE
LL,P, i.ender'sAddreat QTY:1, MECHANICAL PERMIT i •E ''. AF
E.
OW I certifythaOnavereadthisapp'czlionand statethattheabovelnformation
a incorrect.Iagree rocomply withal]city and county horizeinanonlaws P ISSUANCE PEESP(�I
mcor'S�t9
} relalingbullding construction,and hereby authorize rcptesentatives o(thb
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTIRO DDTOMECH, Da[C RCCCI I#
(We)a .to save,indemnify an d keep harmless the City of Cupertlno P
V egal t u ,judgmetda,casts and expenses which may In anywayacaue AIRIIANDIJN 7(17010,000 SUBTOTAL: U
ago 1 in consequence of the granting of this permit. a AIR HANDLING (oven 10, c• ) CONSTRUCTION TAX
n t nt/Con"ac ur m e%HAusmooD(W/D T) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Will theappllcint or umm building Occupant store or handle hazardous HEATING UNIT(TO 100,000 Date Reeel t#
Oulerlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVFRI ,D00 TOTAL:
Fly. M No
WEI the applicant or tutum building Ompant use equipment or devices VENIILAnONFA INGLE RES ISSUANCE DATE
which emit hazardous air contaminants as defined by.the Bay Area Air ^
Quality Management District? BOILER-COMP B'OR 100,000 BT PAID
4Yes ❑❑No /wF
havercadthehazaJousmaterialsrequirementsunderChapier6.5 BOR R . P(OVFR100,0008NI n(��
As the Cali(Omia health&Safety Code,Seettom 25505,25533 and 25534. I ,/I
understand that if the building does not currently have a tenant,that it it my, NEW SIDENTIALMECH. SQ.N.
nspmalbllity to notify the occupant of the requlremenbwhicn mu at be met -
phor to issuance of a Cenlficate of Occupancy.
Owner or xulhorbed agent Date ISSUED ItYJ l]Ijl7\V\x'"a••�
TOTAL:'
OFFICE COPY