19468 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addren: _I kr '�,�s v�.uR Itq � �T 19468
CreenVre taL//_�
CITY OF CUPERTINO-BUILDING DIVISION
Co ad rsNan, Nn: APPLICATION / PERMIT 4 —11 — qct
_
Lk.No: BUILDINGELECTMCADPLUMBINGMECIIANICAL CATEGORY CONTROL N
Mtect/ ser ♦ �
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO.
♦� a `✓� PERMITISSUANCE 2l OO
LI INS ICONTRACFO DECLARATION
Iherebyaffirmthal arelicensedunder pewisionso(Chapter9(commene- APPLIANCFSRESIDENTIAL - JOB DESCRIPTION
IngwlthSeWon7000)°fDlvlslon3oftheBustn and ProfeselonaCodgand my
license lain full force andkc.#xo PANELS
ns
Licee Class L
Dau Contractor
ARCHITECTS DECLARATION 201-1000AMIS
q�q�uu rcO Zp I understand my plans shall be used as public records. OVER 1000 ANTIS SQ.FT.FLOOR AR� S/SQ.FT.
Fi Licensed Professional SIGNS ELECTRICAL
< OWN[R-BUILDER DECLARATION ^^ s
SI'ECULCIRCUIT/MLSC
owing attermthat
on 7011exempt front
essad Protestors
Code:Law ice the g"QQ ss"O�� /Q•
pp following reason.(Section 7 tto Bmtmd and Pimp ons eml h, d r O Yb
OZi- Y city TRMI'.MEI'FR ORI'OI,E INST. f
Fig muntycture requiroaperMttommtequiretheaprovgt for such mpair
'
ray atmdurc prortostatement
hat he is also requlmsuant t the far wions of permitto
ppyygg DEVICES
O�� file a signed statement that M la licensed pursuant to the provisions of the
µ Contractori Llcetue Law(Chapter9(mmnencingwlthSM1on7000)o/Divi-
30r^ slon3o(the Buteressand Pedemlons Code)orthat he is exempt therefromand SWP4MING IC)OL ELECI'RlC 1 VALUATION
the basis!or Ne alleged exemption. Any violation o(S,cHon 70115 by any _3 I3 / I UA r O A
Oa
applicant fees permit subparts the applicant to a civil penalty d net more than OUTLETSSWITCHFSFIXTURES I '( 2/
five hundred dollars(g.50O). NEW RESIDENTIAL ELFLTR
ni,as owner of the property,or my employees with wages as their sok SQFr. tSb
STORIES TYPE CONSTRUCTION
C compensation,will do the work and the structure is not intended or offered for Q
5a�O sale(Sec.7014 Retiree,$and Professions Code;The Contractors License Law 1
qs� does not a pply to an owner of property who Wilde or improves thereen,and OCC.GROUIa RES.UNITS
w who dmessuch work himself or through his own employees,provided that such I
Improvements are not intended or offered for sale.If,however,the build Ing or TOTAL; r
improvement is sold within one ratrofcompletion,the mener-builderwill have
,IA4u ellen of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the pmperty,am exclusively contracting with licensed ppgMl.I•L55UANCE r1
contractors to meatruct the pmjed(Sec.7044,Business and Professions Code: 1
The Contractor's License Law time net apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Improves thereon,and who contrasts for such ptojects with a
cgpj(ct
aor(s)licensed pursuant to the Controls License Law. FEE SUMMARY
1_I I a ,empt under r. B A Pf for this mown BACK FLOW PROTECT.DEVICE
Owner �a. DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
—_Dam
` RECEU'T p
WOR KMANC MPFNSATION of
to FTR711RES PER TRAP SCITOOL TAX Y N
QI hereby atBrm that I have o leammee of cmnaent to opf there. or BBCF�PI'N
380ificate,Lab C.Workers'Compematlonlmunnce oracertifled copy thereof(Sec. GAS PA.SYSTEM-1 EVC4 OUTLETS PARK PIKE Y N
3800,leis C.)
ComPolityan CAS-rA.SYSIT Kd OVER 4(FA) DING DT M
Y BUILDING DIVISION FEES
Cerlfied copy 6 herebyth the city GREASR/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE a•yUlr
�Certifled copy b(Iced with the city inspection division.
CERTIFICATE OF O(EM PTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date Remi t#
(This section need not becompacted gibe permit b!ce cam hundred dollars
($1I mAilcss') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertl(ythd in the per(ormanceofthe work(orwhkhthis permit is Issued,
1 shall not employ any person In any manner w as to become subject to the WATER�,� /'1R[ATING
W°rkeri Compensation laws of California Date PAID
O Z Applicant
NEW RESIDENTIAL PLMB. SQFL Date Remi t#
Z O NOlicant MPL[CANT:IL after making this Certificate of Exemption,you
should become subject to the Workeri Compereatlon provisions of the Labor D TOTAL:
CC W Code,you It forthwith comply with such provisions orthla permit shall be a
> deemed revoked. /3
ac CONSTRUCTION LENDING AGENCY SEISMIC FEE 2-1.Iff
Z IhembyafOrm thattherela t
a co.rodionkndingagenryfortheperform- TOTAL: ELECTRIC FEE /��♦7
ance of the workfor which this permit b leeued(Sec.3097,Civ.C.)
U O Lender.Name t, PLUMBING FEE
LL F Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certllythat l have read thlaappRcationand statethattheabove information ,.
S iscomd.I agreetocomplywlthall dtyand county mdhanceaand stale laws PERMIT ISSUANCE 12,06 FEES PAID:
>. N relatingt ding mrutmdioe,and herebyauthorze representativn o(thla
H Z dtyt teru nth.above rationed property for Inspection purposes, ALTERORADDTOMECH, Date Recei t#
V — e)ogre to save,Ind an d keep harmlea the City of Cuperiro
a Wtllab' les,jadgmen +vete rad expenxre whkh may nary aya.e AIR HANDLING UNIT ITO 10,0(ta CFM) SUBTOTAL: `
aWl Cmym
teal e o begranting of this pc IL G• AIR HANDLING UNIT(OVER]O,000CFM) CONSTRUCTION TAX �Z
Slgwture of Applicant/Contrado ae D IXHAUBT HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7ARDOUS TERIALSDISCLOSURE
Will the applicant or future building oceu pant store or ha rad le hazardous HEATING UNIT(TO I OOpW BT(1) Date Reeel t#
material as dented by the Cupertino Municipal Code,Chapter 9.1 7,and the
Ilealth and Safety Code Section 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL: Q
Yes M No
Willthe applicant cefuture building occupant useequlpment or devices VENTILATION FAN(SINGLE RESID) I$ ATE
which emit haementsdrrict? ntsasdeRned by the Bay Arca Air
Quality Management District? BOILER-COMP p]-BrOR100,B(D BTU) APR
r♦ 'l 7 MU 1
ca No '{rI( 11 1JJV
ve ad the hazardous materials requirements under Cha pier 6.95 of BOILER-COMP(OVfR 100,00)BTU)
I ecalifor is Health, dy Code,Sedloru 25505,25533 and 25534. 1 �pNs�
edemta thatif oes
,bull gdnotmrrentlyhavealenanLthatitiamy NEW RESIDENTIAL MECH. SQFCity. of CII^?rtlp0
.P.. Ilityton Ifythe meant of the requlremenbw Ich 1st be met �7
prior Esso cc riRc teofOccupanry.
oraulhorized agent Da TOTAL: L f ISSUEDBY: Tf./J-ti'1
OFFICE COPY
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