19694 (2) ;PPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro+en Identification -PERMIT NO.
Building Add...: 1 9 6 9 '
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re ante: Phone:
JOSE.vH ?A21L As�_,oc_ zg-ZCI25 CITY OFCUPERTINO-BUILDING DIVISION a iglgo A
eftArac�td+,1.�Nam5e; APPLICATION /PERMITHr —so,-214 SOZ9.SBULDINFLBTRICAPLMBIG-MPHA
CL CATEGORY
LN4AAeer
ELL I 0 T�h C — I gb QTY ELECTRIC PERMIT FEE BU LDING PERMIT INFO
Addrcea5G,�ty waf'��t_Tt.
PERNIHISSUANCE Q
LICENSED CONTRACT R'S DECLARATION
Iberebyeffirmthat lam Bcaund under provisons of Chapter9(commenc APPLIANCES-RESIDENTIAL LJOB DESCRIPTION
Ingwith SecUdn7000)of Divlslon3 oftheguslneasandProfession sCode,and my
Ianse lain fu andeffect. PANELS
Llense Clas. Lisp `J 0'Z S
Date2 IContnct _
ARCHITP S ECLARATION x11-000AMPS
X20 [understand mypl.u.hallbac
e dupublicreoords. OVERIODOAMPS SQ.FEFLO
ORAREA $5Q.FT.
Licensed Professorial SIGNSELECTRICAL I pp -1 —LI V I N 6T 741'V2
{��f�uuu OWNER-BUILDER DECLARATION -
;5 Ihereby affirm that am exempt from the Contrectim'e License Law for the SPECGLCTRCUIT/MISC �r �7
following reason.(Section 7031.5,Business and Professions Code:Any city or TFAfp METEROR POLE I ST.
j county which requiesa perrottororutmct,alter,Improve,demolhh,or repair
i any.tmcture prbrW"2410�wr.
uance,aLw Ireathe applicant fonucM1 permit to
1 U file a signed statemt he h 11 c pursuant to the provisions of the TOWER DEVICES
Contractor's Licens (Chapter ndng with Section 7000)ol Dlvl-
i3SWIvIMING IDOL ELE C
sion3 o(lhe Businerofessbra e)arthat hebexempf/here(romand `1 UATION
the basis for the alptlo y vinlaHon o(Sectlon 7031.5 6y any OUTLETSSWITCHESFI - - �/ A41�
appBantfora'pemathe canttoa vii Ity ofnotnnreilum (/
five hundred dollat NEWRPSIDENTIALELECTR FP.
OL a.owner o ,o irry etppb It ages a their..le �' STORIES TYPE CONSTRUCTION
compensation,will ork'an h t u 6 i dedorofferwlfor
j q
In(Sec.707y Busd I� �e he ontattot.License Law /t
:$ docs not apply to af ho IWs or improvetherton,and OCC.GROUP RES,UNITS
whodoca.uchworkhlmae ghhisow empldy.c'pmvldcdth.t.ch -
Improvemenbarenotinre ed rofferedforsale.l(however,thebuildingor TOTAL
Improvement bold within oneyearofcomplatlon,the raa er-bullderwlll have
'burden of proving that he did not build of Improve for purpose of sale.), QTY. PLUMBING PERMIT FEE RbUD—ZONE APN
U L as owner of the property,am exclusively contracting with licensed
centacmn to corutruct the project(See70iy Buelnens and Professiou Code: PFRMITISSUANCE
The Contractor's License lAw does nor apply to an owner of property who
— . ALTER-DRAIN hVENT-WATER[EA)
Wilds or Improve thereon, and who contracts for such penjects with a - -
attbr(s)licensed pursuant to the Contractors License Law. FEE SUMMARY[am exempt under Sec. - B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSM,
\ ` DRAINS FLOG ROOF, SANITARY Y N
G Date R AREA'GOND. RECEIR 0
JWORKMAN COMPENSATION DECLARATION FIXTURES PER.IAAF SCI-1001.TAX Y N
thereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT N
1 .darsofWdrken'Compeuationl==moramni(Wd pythemof(Sec. GAS EA.SYSTEM.1 INCA OUTLETS PARK FEE Y N
.00,Lab Cdr RECEIPT M
Policy#_emeKkO►J'T �t � GAS FA.SYSITM.OVER 4(EA)
Com any BUILDING DIVISION FEES _
9"Certifind copy b heed with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCp1 ECK FEE ((JJ
Certified copy l9([led with the city inspection division. % ��•3Q
CERTIFICATE OF EXEM PFION FROM WOR KERS' GREASE TRM PAID 0S`>'/S
COMPENSATION INSURANCE I
SEWER-SANITARY-STORM EA.200FT. Date RCCfI l#
(This section need rad Mcompleted If the permit h(mane hundred dollen
($100mless.) WATFRHEATERW/VENT/FLECTR ENERGY FEE Y_ N_
nor
thatlnthe persoalaoflmannerforwhlbeconnerrNH.6sued, J +�
I orke m employ tion lA an in anli manner ed u to become subject to the WATERSYSfFM/TREATING /
Worker Compensation Lawe of Glifornla.Date PAID "Z/40 5q/
sqAppNEWRESIDFNDALPLMB. SQ.Fr. 19 Date RCCA t#
should E TO a subje ANT:eWorr rs'Co per Ction pr a is ons oft
Esernpbry yw `I'yj.
should becomesubject Worken'Compcuation provision.ofthe Labor TOTAL: / 1
Code,you
deemed revoaked.ked.rhwith comply with each provbbu orthta perMtahall be BUILDING FEE Q
CONSTRUCTION LENDING AGENCY SEISMIC FEE /
Iherebyaffiml that there V a construction lending agency for the perform TOTAL ELECTRIC FEE
r fl ate
ance ofthe work forwhich this permit b issued(Sec.3097,CIv.C.) s -
I<ndere Name PLUMBING FEE
Lend,e.Addm.a QTY. MECHANICAL PERMIT 1 FEE MECHANICAL:FEE
'
I mnRythat l have read thi.appllatbnarad statethatthesbove information +
f isdurect.I agree to comply with all city and county ordinances and state laws PERMITISSUANCE .On FEES PAID:
relating to Wilding coutruchon,and hereby authodae representatives of thh
city to enter upon the above-mentioned property for Inspection purposes. ALTIRORADDTOMECH.
(We)agree to save,indemnlfy.an d keep harmless the City of Cupertlrro Date Receipt#
against liabilities,judgments,costsand expenses which may In anywayaccrue AIR HANDLING UNIT(f010,000 CFM) SUBTOTAL: _
mt sold City In mnsextuence of t granting of this Fermi.
2 /$ O AIR HANDLINGUNl'f(OVER IO,ODOCFM) CONSTRUCTION TAX ^�.'j
S tumof Applicant/Contract. w EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllant or future building occupant store or handle haeardous HEATING UNIT(TO 108000 BTU) Date RecC' t#
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
l ke lth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL.
O Ye MN.
Will the applicant or future Wilding oompant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit Fazardous air conlartilmnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP p11P OR 100,000 BTU) se•C9��,
4Yes n No �P
hav°rudthehu�ousmaterial.requirements uodc,Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the Califomia I ealth h Safety Code,Seetioe 25505,25533 and 2553/. I
understand that ltlhebuildtng does not currently havealenanq that It is my NEW RESIDFNRAL MECH. SQ.FT.WT UM'
M+I, O I t93U
repoulbillty to notify the occupant of the requirements which must be met 111
prior to issuance of a Certificate of Occupancy.
CIOf CnngrtinO 043'
Ownerorauthorimd agent Date - - Y.�T'�"<If
TOTAL: . SSUED OY:
OFFICE COPY