19666 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proven Identification P�ll NO.
Building Add.: 19666
102--1141 eAwaWtl VeJ assassass
OwnersName: cif A
CITY OF CUPERTTNIZLBUILDING DIVISION
Lic.No: APPLICATION / PERMIT
icere A2AW'0WA't 624!T516 BLJTLDINr—ELECTiUCAIPLUMBINr—MECHANICAL CATEGORY CONTROL
Architectlagmacr. Jor Lic.No:
,.I' 11�'sf"' W BUILDINCPERMITJNFO:
ELECTRIC F JE
Add.. PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affiron that I am He="under provisions ofChapter9(comment APPLIANCEBRESIDENTIAL JOB DESCRIPTION
i.gwithS,di.n70M).fMvi,i.n3ofth.B.el...dPmfese...Codo,eulon)
I bin to q#d offed PANELS
E-011cu-Z AK IF 91 ."'L"Oe A
Date_Ff,,a_Z.A_Contra t.r did/.
C'IT CrS DE RATION 40B)AM
AR H TB 201
9 z0 I understand my plans shall be used as public reconlL OVERIODOA?APS SQ.F
r.FLOOR AREA $/SQ.Fr,55 Licensed Pi. Tonal
SIGNS
g E; OWNER-BUILDER DECLARATION SPFCIALCIFC
I hereby affirm that I arnexampt from theContractor's Licarse Lxw forthe—
following reason.(Section 7031.5,Business and Protest ..Code:Any City or TEMP.METERO LE
mu lywhi&requbnaparrnitwmrutructalter,lmpr edem Ushormpair—
anystmeturepriortefts nce.alsoaequlnstheappB¢ntforsuch permitto POWER
DEVI
ii pursuant to the p ion,of the
o. file a signed statement the he Is heron
Contract.e.License Law(Chapt.,9(
ncing 7")of Owl- NG)P6OL C VALUATION
sion3ofthellusinessand PrdessbnsCod0orthathe exempt therefirmnand
the baes for the alleged exemption. My violation of Section 70315 by any 0 ETS 1C FI
appUceit for a permit subjects the applicant to a civil penalty ofnatmorethan
five hundred dollen W5001. L I. EQFT. STORIES TYPE CONSTRUCTION
1,as owner of the property,or my employees with wages as their sole
compensation,.01 do the wcak,and the shuctom is not intended or offered for
Fo see(Sc.70K Rosindes.rul Pndnaid.Code:The Contractors License IA.
does not apply to an owner of FmpoV who builds or improves I hennor,and OCC.GROUP RES.UNITS
who doeswchwark himself or through his own employees,provided that such
m �
pe"ntsmmintendedaroffemd(orsale.ILhowever,thebruildingor TOTAL.
Impmvementis*Wdveithtnonerarofc=pldi theowner-buUderwlllhave I- � - �"�"FE'
t[]L...of 9 E' ___FL_0�DZONF
heburdencdprovin thg�dW�bruddarimp��f.,prp..f.l�.). PLOMJdf��GiERMITAPN
the property,am exclusively coatrading with licensed PERmrrISSUANCE k
coomsetcaa to constrod the project(Sec.7016,Business and Professions Code: I
The Corleactur.Lt..Law does not apply to an owner of property who ALTER-DRAIN&VENT'-WA
TER MAI
Wilds ai Improves thenar, and who contracts fu such pkojects,with a
actmW Hamsed pursuant to the Contractor's Ltd.Law. FEE SUMMARX��
C15m 1 am exempt under S �B&P C for this BA_CK FLOW PROTECT DEVICE Liu I h.IjL 1,I,o
Owner Dat, DRAINS-FLOOR ROOF,AREA GOND. SANITARY Y_ N_
RECETT#
r1l
WORKMAN COMPENSATION DECLARATION FDCTURF_S�PER TRAP SCHOOL TAX Y_ N_
hereby affirm that I have. rilficah,of consent to self-masure,ce RECEFT
certificate ofWorkers'Codpiencitionloscronerma dortified copy thereof(Sec. GAS.PA.SYSTEM.1 INC.4 OUTLEIS PARK FEE Y_ N
MOO,Lab C C RECEIPT N
Policy# GAS EA.SYSTEM.OVER 4 IBM BUILDING DIVISION FEES
Com
y
4nitiftecicopyis encloyfumishe,I. cREASE/INDUSrRL WASE INTERCEPTOR PLANCHECK FEE
Certffied copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANBTARY-STORM EA.200FT Date Remi t#
(SIOD)culdej ENERGY FEE Y N
I certify the to the performmee of thework forwhich IN,permit is Issued, WATER BEATER W/VENT/ELECTR
I siha U not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING PAID
WorkdaC.mp,m.mmLaws.fCeifcmua.Data
Appli ot Date Remi t#
z NOTI. NEW RESIDENTIAL PLMB,_SQFr Dale Kem' IN
0 CETO APPLICANT:If,after makingthliCertificate.d Eadoptlm,,you TOTAL:
should becturs,subject to the Workers'Comperastion provisions of the Labor T
03 Code,you=9 forthwith comply with such provisions or this permit shallbe
> deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC EE
FEE
FEE
L TOTAL: SEISMIC
Z ance of the work for which this permit 4 Issued(Sm 3097,Civ.C.) PL
0 Lerider'.N. PLUMBING FEE
I- Leml.AAddress MECHANICAL PERMIT".: FEE,• L FEE
0 1 ardifythatl have readthisapplkatimand AAtrth;J_he.b._._m_f..ti.. ja
U) Ice correct lag�tocply�th.Ildtyand.unty.�i..n...do.telaws PERMIlISSUANCE FEES PAID.
0. relating to building construdion,and berebyauthmirereprewntativesofthis ji�
U) dry to enter upon the abow,mentlatud property for inspection purposes. ALTERORADOTOMECH. Date Receipt#
K (We)agree toave,mdemnIfyaAd lucp harmless the City of Cupertino
gai.tUbiUt�,odg..t,,...nde.pe..which�yinanyway.�e. MR�NDLING UNIT GO 10,0a)CFM) SUBTOTAL:
against said City in consequer��ufft. AIR HA NDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Qx"tr je —
Sig jr.fAppIi.m/Cmha Dec DJAUSr HOOD(W/DCTCONSTRUCTION TAX PAID:
HAZARDOZMATERIALS DISCLOSURE
Willthe appilant or future bullctiognedipant store or handle ha�ardous HEATING UNIT CIO IOD,000 BTU) Date Receiptlif
conerialasdefined by the Cupertino Municipal Code,Chapter 912 and the
Healthand Safety Code'SccUW2S532(4? HEATING UNIT(OVER 100,000 BTU) TOTAL: '7.
qYes .
fllth,a ppb.of or r .building oavpant use equipment or devices VEN TILATION FAN(SINGLE RESID) ISSUANCE DOTE
which emit harardous air contarrumets as defined bythe Bay Area Air MD'
Quality Management MLtrigckx� SORER-COMP(31P OR 100,000 BTU)
C?Yes11�-
, read the haaardous materials requirements underChapter6.95 of BOILER-COMP(OVER 100,000 BTU) 1- 01990
the�7,ifo.i.H..Ith&SfetyCode,Sedi..25505,25533and2S534.1
understand that if the building does not mmcrtly have a tenant,that It is my NEW RESIDENTIAL MECH..SQFr
responsibility to notify the occupant of tAe requirements which=at be met C,tv of PrIT-direft
Ow r authortard agent Date TOTAL: ISSUED
OFFICE COPY