19616 (2) - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'cct Identification PERMIT NO.
Building Address: 19616
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,n✓ CITY OF CUPERTINO-BUILDING DIVISION '
c tract. . ams: Lie.N. APPLICATION /PERMIT
BUILDING-MBCTRICAL]'LUMBING-MECHANICAL CATEGORY CONTROL#
ArcMtect/Engineer,• Lk.N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PFJMTISSUANCE 1:1 El 11
LICENSED CONTRACTOR'S DECLARATION
., I hereby affirm that l am licensed undei provisions of Chapter9(cnmmcro APPLIANCFSRESIDE L JOB DESCRU-ITON
Ing with Section 7000)of Division 3 ofthe Buslnewand ProfculonCocie,and my
license is in full farceand died. _ PANELS
Class p
Date
VVVV
Y ��
ARCHITECTS DECLARATION 201-1WO AMPS
reO Zp' Iunderetand my plane shag be used public recoNa OVER 1000
SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SICK C
$< OWNER-BUILDER DECLARATION , LCTC J LSC
7E, I hereby affirm that I Anmempt fmmthe Contractor's License Law for the
following reason.(kdl.n 70315,Basins.and Profession.Code:Any city or
county which requires.penNt tomntmct,alter,lmpmve,demolhh,orrepelr P. I'O INST.
g is aWdureprl.rta Rshat he i aive.sed! .ratumt to the
mvftrhpermitl. pOWERD
E1 O file a signed.tstement that he h Il9 pursuant 1t the pro 7000) of the
Contractureusinv l dPrupter9(mm)orthathele mptthemfof Divl- SWIMMD A70L ELECTRIC ,VALUATION
SOS the basis sHhe the aIle e d .Anaptk,n. A y vi.lhat heh exempt therefrom and
Sn the n for the alleged exemption. Any vlolacon of Section nat by any OLTMETSSWITCHESFlX.I.URES
applicant fare permit vubjectetheappgcantloa civil penalty Wna m.rethan
�Iu,nads owdndeor len w NEW RESIDENTIAL ELPLTR
SQ.FT• TYPECCONSTRUCTIONoft¢ .perty,
or my employees with wage as(heir wk
�7C at&n. 044,Business andk.anssionsmdureThehn Contractors
ntractor orcense Lfor
O doe(Sec.apply
to Business andProfessions
pmpeon who builds
or Improves
License law
$$
does Act apply toanownermpropertywhobuild.orfmprwcathereon,and OCC.GROUP RES.UNITS
.h.d.Lraswork t Intended
oroogh hisown employees,provided that such
improvement issold am iNended earo(c mplett c.n,If, owne,.b.ilderwill have
t TOTAL:
Improvement b cold within ane ycarof compldlon,the owner-builder will have
01LIIunieo of pmving that he did ro Wild or Improve for purpoec ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u1,as owner of the property,am eulusively contracting with limned pp (R ISSUANCE
to construct the projed(See 7044,guide.and Profeasimu Code:
The Contractor.Llan.law don rad apply to an owner of Property who ALTER-DRAIN kVENT-WATER(FA)
builds or Improves thereon, and who mntneb for such plojeda with a. FEE SUMMARY
cgp((actor(e)Bcm.dpunuantlothe Contra do's Lke aw. BAIX FLOW PROTECT.DEVICE
QUTSIUEFEFS
IJ I am exe t under e. B E.J.
this r as n
�s Ua1 DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
AN COMPENSA ON DECLARATION RFxF3I''f#
❑1 hereby of 1 that I have a mrtiBcate of consent to.ILinare,or
FIXTURES PER TRAP SCHOOL TAX Y N
artl0cateofWor n'C.N.HonI...aoraartifled copythenof(Sec. RECEQefa
3800,Lab C.) GAS EA.SYSTEM-]INCA OUTLETS PARKFEE Y_ N
.Airy Y RECEIPT M
Com GAS EA.SYSTEM-OVER d(EA) BUILDING
DI VISION FE[S
CerIfiufled copy B hereby furnished. CREASEANDUS RI,WASTE INTERCEPTOR PLANCI-IECK FEE
6 CerHEed ropy Ie filed with the cityWpedlon division,
CERTIHCAT11 OF EXEMPTION FROM WORKERS' CREASE TRAP PAID .
AmCOMPENSATION INSURANCE SEWER-SANTTARY-STORM EA.200Ff.' Date Recel f t
(f)m I..)n neM nrR M romplMed If the permit hfor one hundred dollars
'($1 W)drfy that
WATER HEATERW/VtNT/ELDCTR ENERGY FEE Y N
" fartifythat Nthe performance of the work for which this permit is issued,
Ishall nm employ any person In any manner an as to become subject to the WATQt SYSTEM/TREATING "
Worke%Compensation laws of California. Date PAID
z Z Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date ReL'ei f# •-
Z O NOTICETOAPPLICANT:1f,aftermakingthb Cedifluteof Exemptlon,you
should become subject to the Workers''Compemation pmvlslon of the Labor TOTAL:
W IxW Code,you moat forthwith comply with such provision orthis permit shall be BUI•
j deeed revoked. .
a CONSTRUCFION LENDING AGENCY SEISMIC FEE
I hereby afOrm Hut there h a construction lend Ing agency for the perform ELECTRIC FEE
Z ance of the workfcr which this permit is hmed(Sec.31197,Civ.C.) TOTAL:
U O Lander•.No PLUMBING FEE
LL Lcadar'a Address - QTY. . MECHANICAL PERMIT ' 'mMECHANICAL FEE
OW Icertilythal l have mad this applicatlonand statethat theabove beforation IT
11 Is cormct.]agreet.c.mply with allcityand muntyoNinanas and.tate laws PERMIT ISSUANCE •� FEES
t;;
ting tobullding c.nstrucim ,and hereby authorize represemativea ofthh ` _1
r relating 1J
Z ' city to enter,upon the above-mentl.nd property for inspection purposes. ALTER ORADDTO MECIL
(We)agree to ivn,Indemnify an d keep harmleu the City of Cupertino Date Recei t#
V against llabllltin,judgments,costs and expenses which may In anywayacerue AIRHANDLiNC UNIT ITO 10,ODOCFM) , SUBTOTAL:
sgelnt uid CityIn cona quence of the granting of thls permit.
MR HANDLING UNIT(OVER lB,000cFM> CONSTRUCTION TAX
Signawmof Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfulure building occupant stare or handle hazardous HEATING UNIT(TO 100,000 RTU) Date Recei t#
rb
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
ITrzlth and Safety Code,Section 25532(a)7 HEATING UNIT(OVER 100,0W BTU) ,TOTAL:
❑Y. o
Will the applka or mrc building.=part use equipment or devices VEND LATION FAN(SINGLE RFSID).' ISS{,[{1�1�DATE
which emit haurdous air contaminants as defined by the Bay Area Air rH/(7 -
Qo lity,Me nagement Db&? BOILER-COMP(3FN OR 100,000 BTU)
Yn Na FEBilluvereadtheh nus=kdah equirem nb underChapter&95.1 BOILER-COMP(OVQt1W,000 BTU) U U,( 19SU
the California Health A Safety Code,Section 25505,25533 and 75534.1
uruleniandthatlfthebuildingdoesnmmrrentlyhavealenant,thatitbmy NEW RESIDENTIAL MECH SQ.FT.
A. 'bility to ndlfy theca= ant of the requirements which must he sect rll Q{ CH17P 1
Prior Isauancc of Certiflcat (O a ry. b
nor authorized.gen rt }—�
It TOTAL: 1l. ISSUEDB
OFFICE COPY