19855 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
HuIId1nX Prom Identification PERMIT NO.
Building Address: 19855
4j30 S- 0E A,v�l bwa PUrTE' /2o c�G /ua --Aw ante: Phone: p -
n1.U�a(J /-�trG�(/C�+G,t; ap$, 353-615- CITY OF CUPERTINO-BUILDING DIVISION
t-x. ran° •"•^�: APPLICATION / PERMIT 1
-�? ��_C CTrE BUILDINGMECTRICAL.PLUMBINGMFLHAMCAL CATEGORY CONTROL X
Archltpct/Engineer. Lic.Nee
T//dMA� �bcJpAC,J C 7g BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
AaaresaBLDG UECI PLUMB M=
err. PERM ITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am hemsed under provisions of Chapter9(corr risme APMANCFSRESIDENIAL 70B DESCRB'FION
Beer.
I.foll 7mm)ond offoon3o(the Businnsand Pro@WoneCode,and my
Iimnre Is In m orce and dfect. _ PANELS
LlmnseChs —Lin N
OF} )fcj;, Contractor •'-> �1-
/ / AKCHITECI•gD CLAR��AThO��� 211-10DOAMPS
reO Zp Iunderstand my plamahall be used as public records. OVERIOWAMPS - SQ.FT.FLOOR AREA $/SQ.FT.
fG Licensed Professional SIGNS ELECTRICAL
G 6 OWNER-BUILDER DECLARATION
I-na� ID SPECLILCTRCUIT/MLSC 11VC.1S
ZF,vII I hereby affirm that I am exempt from the Contractor's License Law(m the
following resn.(Section 7031.5,Business and Professions Code:Any city or
O TEMP.METIX ORPOLE INSf.
I"' county which rrqulresa issuar aLsorugalter, aprovamfors ch,orrepalr
1� anyatmeend p Cementiorto that
M ix aiso sed pursuant
t the pormkons of it e
K
Me a signed outsmart that he is licensed pursuant to the provism.of the POWER DEVICES
Contractor's License 3Law(Cha Mer9(comerencm thehhSection7000)o(D1vi-
SWIMMING POOL ELECTRIC
OS tlon3of(he Bucins
nand Pro(emloro Code)orthat heisexemp[lhem(romsnd VALUA710N
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES �, ('�'� /t G r x
applicant for a permit•iblects the applicant to a civil penalty of no more than V
five hundred dollars(5500). SQ. SIpR1• TYPE CONSTRUCTION
,$ NEW RESIDENTIAL ELECTR FT.
I,as owner of the a weak,
property,or my employees with wage r thele sole
compensation,wllldothe wmkand lM1eatmdureisnot intended or offered forGlcm
q
-1.(Se.70K Budeseasand Preheat..Code:The Cmdradml'a Licerue U.
�$ does not apply to an owner of property,who builds or Improve•therm,and OCC.GROUP RES UMTS
EE who does such work himself orthrough his own employees,provided that such
Improvements are not intended oro/fared forsale.If,however,thebuilding or .� TOTAL: 4LN
Improvementissmld with lnomyearofcompldi mtheowner-bu0derwgI have
tl)Ckurden of proving that he did notbulleforimproveforpurpneofule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed f
contractors to meatmct PERMIT the project(Sec.7044,Business and Professors Code: ' \
The Contndor's License Law done not apply to an owner of property whoALTER-DRAIN&VENT-WATER v\ 11
builds or improv.thereonco
,and who contracts for ouch pAuleds with a • FEE SUMMARY
mm
l.) pursuant to the Contrad&.License Law. BACK FLOW PROTCCT.DEVICE r
LII am exemptunder•See B k P C for this reason 4as� OUTSIDE FEES
Owner' Date ( NSFLOOR AOO ser AA , NaD.v 4 I SANITARY Y_ N_
EIf[�m� RECEIPT X
WORKMAN COMPENSATION DECLARATION --("i"-6 PER 7RAPp SD{DOL TA% Y_ N_
i,Llr nereby affirm that I have a certificate of consent to self-(nmre,or -iM _ep, F�� c* RECEIPT N
Jt +•3800t1UbC)Worken'Compnruatlonlrounna oraartlficd mpythereo((Sec. G x .SYSTIXj WCA OU1LhTS PARK= Y N
Poliry N d I �L '•3 LI�� _� - RECEIPT N
CASH .SYS5WjPVER4 )
Com env :Y1F.. �y.-c e„2. tis BUILDING DIVISION FEES
Certified copy b�by�umle city GR A;JEIRL WAm9i e R PLANCHECK FEE
Certified copy is(Ikd with the city Impaction division. 4
CERTIFICATE OF EXEMPTION FROM WORKERS' G
MREASE PAID X13-40
COMPENSATION INSURANCE SLIVER- AIY-STORM FA Date Recei t#=A(rhissedmn need not be completed If the permit is(prone hundred dollars
(5100)mine.) WATERHEAT£RW VENT/EI, q,4;
�.-s ENERGYFEE Y N
I certify that In the performance o(the work forwhich this permit 1.timed, v
I shall not employ any person In any manner so Is to become subject to the WATER SYSTEM/TREATING g^.1�0
Workers'Compenution Uwsof California.Date PAID 43 ' / Q
C' Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date RCLY'I t# POOL
Z Q NOTICETO APPLICANT.If,after making this Certificate of Exemption,you u
should become subject to the Workers''Compematlon provisions of the Labor 1- ,�.Ns.an p'- TOTAL:
F y Code,you roustfo hwithmmplywith•uchpmvisiomorthis perMtshallbe `••=H'P o'er' S�1Q-•N V
2 j deemed revoked. . _HU
DI G c
6. G CONSTRUCTION LENDING AGENCY VV>'CWki'L P%neIPS 01,CZ cp ELECTRIC FEE
CZ SEISMIC FEE O
(hereby a(firmthat them is a meatmdlon lending agency forthe perforce TOTAL: -� 4 (�
Z arm o(the workforwhkhthis perMtislwred(See 3097,Civ.CJ
V O Lmder.Name PLUMBING FEE
F Under.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE 14 Aib_
O W Icertt.Iagree aveto
ad mplywappll ritynand•taty ordinances
above information
6 isming to agree to complywith andhereby
ere yauthoordinancn andstateelawe PERMIT ISSUANCE 1�AL90 PEES PAID:
�. city to gmbuilding the
e above,oganddpropauthorize representatives o(this
~ N
city to the,indemnify an
n of property for Inspection purposes. ALTO20R ADD TO MECH. 2A 'C,b
Z Date Recei t#
V _ (We)agree to save,Indemnity and keep harmless the City o/Cu accrue P
against liabilities,pdgmenb,caste and expenses which may In any way amue AIR HANDLING UNIT(TO 10,000 CPM) oxic, SUBTOTAL:
aga Wt said City in coneequenm of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/ContractorDate EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha ndle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I Iealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. MN.
Will the applicant or future building omvpant use equipment or devices VFN71LA11ON FAN(SINGLE RESID) e� ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area AU
t,Quality Management District?, BOILER-COMP OII'OR 100,000 BTU) Its
❑ Yes ❑❑No R �
I [have read the huardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Califomta Health k Safety Code,Sections 75505,25533 and 25534.1 •�y ry ❑
-^ understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECIi. SQFT
emporeibilI to next(y theocmpant of the requirements which It be met 1
prim to y emofaCetiflut parry. p l VS VSUaI V (!{Y
Of rUn
nrrora thml dagent Dat ISSUEDBY:�VN1yVs/0'�hValJq'�✓`p.)F tel.
TOTAL: \
OFFICE COPY