19880 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
PERMIT NO.
ai�dds: � so r 19880
Phone:
A
S CITY OF CUPERTINO�BUILDING DIVISION
Contrator'd Name L' .No:11 APPLICATION / PERMIT - �
BUILDINC-ELECTRICALPLUMBING-MFGHANRCAL CATEGORY CONTROLN
ArcLitet/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE El
I hereby hSrdi.affirm that l am Bon3ofheunder rovlandPr(mionsCoddm enc APPLIANCESREADENTIAL IUB DFSCRB'TLON
InenseI in fall forced deffeon3ofthe Buslrussand['roleuiomCode,and my
Licans Is in full force and effect PANElS
Data hss Licit
Date Contractor
ARCHITECPS DECLARATION 201-1000AMP5
Rod l understand my pore shag W used az pubec retards. OVER 1000 AMPS SQ.FT.MOOR ARFA S/SQ.FT.
Limned Pf.m .l SIGN
6. OWNER-BUILDER DECLARATION C
IherebyafBrm that l am exempt from the Contractor's License Law for the
following reason.(Section 7MI.5,Business and Professions Code:Any city or
K��-' county which requiresa t
perenttocorttru ,alter,improve,demoilsh,mospair TEM O I T.
Elt
Q1 anystructure priortolts Issuance,also rcquirestheapplfont forsueh permit to Js
a file a signed statement that he H licensed POWER DEVICES
Contractor' pursuanttothetion7 reof the
F,�O¢ yn3of the Bulsinesscense lnd Pfesslons Code)er 9 rrhat he Lswithexempt th�fromand RIC VAUATION
u`1 6 5
pphdnt fora permit subjethe basis for the alleged exemption. Any violation of Section 70)15 by any Q s00
O n'the a pplicant to a civil penalty of not mare than
fl 4rad ed owner ars of the
pro is
NEW RESIDENTIAL ELFGTR b-roglp5
?¢ W e as owner a(tM property,or my employees with wage as there dole TYPE CONSTRUCTION
rasa'o4 Mild otheovork andthe structure b rat intended or offered for
O vi .s.7046,Buabiew and Professi.re Code:Th.C.otndoi.Limre law
does not apply to an owner fproperty who Wilds or improves thereon,and
who doessuchwork himself orthrough hisownemployees,provided that such gCC.GRO(11' RFS.UIxT[S
1`J
impmvementsamntintendedorofferedforaale.lf,howevepthebuildingor TOTAL:
Improvement issold withinoneyearofcompltiogtheowner-builderwill have
t Men of proving that he did net Wild or improve for purpose ofsals.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed I'FRMI7155UANCE'
contractors to roretrut the project(See.7041,Business and Professions Code:
TM Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EN
Wilds or improves thereon,and who contracts for such p(ojecta with a
C ttactor(a)Ilcensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B&p C for this mason
Ow
ns to DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• ORKMAN OMPEN�A'FIdN DECG7tAT 0 RECEIPT N
affirm that I have a certificate of consent to self-Nsu¢,or FIXTURES PFR TRAP SCI100L TA% Y N
certificate of Workers'Compersatlen Insurance ora unified copy tMmof(Sec. RECEB'T N
MM,Lab C.) GAS EA.SYSTEM-I INC-4 OUTLETS PARK FEE YN
Policy N RECEIPT p
Com any GAS EA.SYSfIiM-OVER 4(EA) BUIL DING DIVISION CertlBed copy b hereby furnished.
Certified copy is filed with the city inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF IX hMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissetlonneed not Mcompirtd lftMpernat isforom hundred dollars SEWER-SANITARY-STORM EA.200FT. Date RCtt'1 t#
esti unify
that
ENERGY FEE Y N
I¢netempoythe
any omni any e ofthe work
ftas to become
eertniHc Loved, WATER HEATER W/VENT/ELECTR
I shall not employ any person in any manner se as m Mdme subject to the orWATTR SYSTEM/TREATING
O Alfnt Compensation awn of GB(arn a.Oats PAID
PP NEW RESIDENTIAL PLMB.
Z OZ NOTICE TO APPLICANT;If,ager nuking this CertBidle o(Exemptlon,you SQ.Ff. Date Recei t#
Fshould bxvmesuMtoth.Worken Compensation Prove,can of the Labor TOTAL:
WN Code,you rwstfonhwith comply with euchprovulore or this perms shallM
> deemed revoked. —BUILDING FEE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hembyafOrm that there l9 a construction lending agency for the perform,
Z and ofthe work forwhich this permit is Luued(Sec.3097,Clv.C.) TOTAL: ELECTRIC FEE
U O Lander.Name PLUMBING FEE
LLI- Lender's Aaarcad QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O
O4 I urtlfy that I have read this application and natethat the above information iaet.l agree to comply with all city and county ordinances and state laws PERMITLSSUANCE 17 $PAI
>. N reconlating to building roretroctlon,and hereby authorize mpmkr.tiveaofjM, ^ v a/1
F Z city to the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
— gree to save,Indem dfy an d keep harmlas the City of Cupsnmo Date Receip[#
ago Wt labigtkro,pdgmems, nd expenses which may in anyway acerve AIR HANDLING UNIT 10,ODO CFM) SUBTOTAL:
.v
agsl sal ity in coreequ ceo the granting of this permit.
z -4gAIRHANDLINC UNIT(OVER 10,OWCFM) CONSTRUCTION TAX
Slgoincm of AppOcant/Contractor r to ECHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS TERIALSDISCLOSURE
Will the applicant or future building occupant stereo,handle hazardous HFATINGUNTT(TO100,0DOBTU)
material as deflnM by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Rceei t#
Yes No
Health and Silty Cade Section 25532(.)7 HEATING UMT(OVER 100,000 BTU) TOTAL:
❑ �
Will the applicant orfu um contamldinginants
occupant ban ytia,Say Area
devises VEMHLATION FAN(SINGLE RESID) ISSUANCE DATE
which eM1 hazy nous air contaMvnb as defined by the Bay Area Air
Quality Management District? BOILER-COMPPIB'OR100,0101HU) 1�119A
.) I Yes �No
CMV
have read thehav et materials requirements 5533underand 25534.
of BOILER-COMP(OVER 1W,000 BTU)
the GBand that if the
building Safety Code, of cu rnntly h ve a to rad,that i 1 MAR 141990
understand that n tifytheoccupant of t erequi mums which
lust it met NEW RESIDENTIAL MECH. SQ.Ff.
prioriresponissuaty nce
matytheicteof cctherequircrmntswhich must be met
prior to issuance of a Certificate o(Occupancy.
Owner or authorized agent Date
TOTAL: ISSUEDBY:
OFFICE COPY