19931 (3) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'en Idemifkatlon PERMIT NO.
Building Address: 19 9 31
azs �: ozena 45o`0041
s came: Phone: p q A
,ser i SNG w y,3ZG CITY OF CUPERTINO-BUILDING DIVISION
cpy/j=rtgora/Nam/y��u� Lie.Ne: APPLICATION / PERMIT
/ef r�aCiSL x!/N3/FNGT eN C SG 7J1 BUILDINGELECTRICALPLIIMBING-MLCHAMCAL CATEGORY CONTROL Xr-/�eT1
Architect/Engineer. Lle No: ]1 L
1 ( BUILD G PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address:jjgjpf&) jqi; PERMITISSUANCE 1:1 El ElLICENSEDCONTRACTOR'S CLARAT N
I hereby affirm that l am licensed under provisions of Chapter9(commmc APPUANCFSRESIDENTIAL JOB DESCIUPHON
ingwith Section 7000)ol DtNMon3ofthe Businmand Profes msCode,and my e
Licer nein(u6 force and effect PANES
EutClass Cmdr
Date Cmdr
ARCHITECTS20
DECLARATION 00 AMPS
ce0� Iundentand my plansaWUW used upubuc records OVEROVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.Ef.
COC
dt, Licensed Prolessbnal SIGNS ELECTRICAL G1 L(7
6 ul O WNER-BUILDER DECLARATION (J
In]Gi SPECIAL CIRCUIT/MISC
F'yd� owinghereby afltrmthat lam31-5,Bfrom the Contractors Lkenx Uy city the
or
09 fogowing reason.(Section 76315,Business and Professions Code:Any dry or TEMP.M OR POLE INA V
I-' structure
prim to it permitroconstmuires the
h 4npmve,der such,ermit tor
q`'6 3 any structure prior tentshushes licensed
pursuant to the provisions
of tt e U
E (OWER DEVI
ry2 y V file a signed statement that he b Ikenud pursuant to the provisions o! the
Ow Contractors License law(Chapter 9(commencing with Section 7`011))of DIV I. SWIMMING LE.EC
30rn sion3ofthe Busineesand Professions Code)orthat heir exempt thercfromand VALUA1lON
the Wall for the alleged exemption. Any vlolatbn o(Sectbn 7N1S by any OUTLETSSWITC FS 8 (Doo
a `cxl�J
d « appu.ntf.r.permitsubjecbtheappucanttoadvilpenaltyofnom ml;an lJ
L" five hundred dollar(5500). NEW RESIDENTIp TR c SQ.FC. STOW TYPE CONSTRUCTION
F-11,as owner of the property,or my employees with wages as their sok
compensation wllldothe work,and thestructure Is not intended or offend for
psale(Sec.764,Business and Profeselons Code:The Contractors License law
(�5$ does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RES.UNITS
E who does such work himelforthmugh his own employees,provided that such
hnprovements are not intended oroffered forsale.If,however,thebullding or TOTAL:
i provemcnt issold wifhinoneyearofcompletion,the owner-buRderwill have
th,t¢mrdcn of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FTOOD PONE APN
L-J L as owner of the property,am exclusively mntraabng with Iirenxd PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Protessimu Code:
The Com rector's Llcenx law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EN
Wilds or Imp.therms,and who comment for such p(ojecU with a FEE SUMMARY
co,p!(actor(.)hornxd pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
Of TT�l Fin P9717Q
DRAINS FLOOR ROOF,AREA,CONE). SANITARY Y_ N_
Owner Date RECEIT N
WORKMAN COMPENSATION DECLARATION FDCNRFS PER TROT' SCHOOL TAX Y_ N_
❑I hereby a/firm that I have a certllcate of consent toself-Inwre,ora RECEIPT N
certificate of Workeri Compensation Insurance ora unified copy thereol(Sec. GAS FA.SYSTEM-1 INCAO0 ECS PARKFLE Y N
3800,lab C.)
RECEIPT N
Policy N GAS EA.SY9TEM-OVER 6(EA) BUILDING DIVISION FRGS
Co any
5Cr Bled copy is hereby fumlahed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
F-1Certified copy Is filed with the city inspection division. //��������..((�
CERTIFICATE OF EXEM PPION FROM WORKERS' GREASETRAP PAID�7�� ;
o "tom" �^
COMPENSATION INSURANCEgryyER.SpM.I.pRY-SIURM EA 2(DFi. Date RCCCI t# l��t
(Chis se«ton need nor be completed tithe permit b(Drone hundred dollar
($100)orless.) WATER HEATER w/VENT/E.ECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhlch this permit Is issued,
I shall not employ any person In any manner an,as to become subject to theWATER SYSTEM/TREATING (]
Workers Compnrsmmn laws of California.Data PAID��'" [^
O Z Applicant NEW RESIDENTIAL PLMB. SQFC. Date Recei til J�c
Z O NOTICETO APPLICANT:H,after making this Certificate of Exemption,you
should become subpeet to the Workers'Compeosatlon provisions of the Labor TOTAL:
IX (1) Code,you most forthwith comply with such provisions orthis permit shall be BUILDING FE' •0Q
deemed revoked.
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaffirm that there isamestruction lendingagency lorthe perloms- TOTAL: ELECTRIC FEE
M Z anmofthe workforwhichthb permit b lcwed(Sec.3097,CIv.C.)
U O Lenders Name PLUMBING FEE
LL F Lender§Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Iordilythat I have read this application and etatethatthe above Information
O W bcomect.Iagree to complywith all dtyand county ordinanmand pafelawa PERMITISSUANCE FEES PAID:
Y G relating tobuflding construction,and hereby authorize representatives ofthb
F N city to enter upon the above-mantioned property for inspection purposes. ALTERORADDTOMECH.
_ Z Date Receipt#
(We)agren tosave,
ems, s andkeep Farmiess the in any Cu accrue AIR HA NG UNIT 10,OW CFM)
V ag ntllabllitles,pdgmnb, As and expenses which may In any wayaecsue SUBTOTAL:
ag st ear City In cons uence of the granting of this permit.
AI
5-� RF3ANDUNGIJNR(OVER IO,000CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor ate IXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAD:
HAZAR DOLS MATERIALS UI SCLOSU RE
Will the a ppllcant or future building occupant store or hand le hazI
ardous HEATING UNIT CFO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Date RCCCI
Health ami Safety Cade Section 25537(a)9 HEATING UNIT(OVER 10[L"BTU) TOTAL: 41a 0
❑ YesN No
Willtheapplfam or( mm Wildinga pantuxequipmentordevias VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality ManagemDistrict?istrict? BOILER-COMP OHP OR 100,0(10 BTM
Yes No PAID have read the hazy mus matedabrequbemnts under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 'AIG
the California Health h Safety Code,Sections 75565,23533 and 75534.I
undersnncLahat if the building does not currently have a wenn,that it 6m NEW RESIDENTIAL MECH. =.R.FT �.1AY 2 5199®
responsibility to notify the occupant of the requimments which most be rnet
prior to Issuance of a Certificate of Occupancy.
Owner or authorized agent Date
TALISSUED BY:
TO :
OFFICE COPY