19676 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Probit Identification PERMIT NO.
Building Add ress: 19676
nese Phone: ' -
12 Aj .
CITY OF CUPERTIN0.BUILDING DIVISION q q•O
. c° tl ',Name' Gc.N. APPLICATION /'PERMIT J ��
BUILDING-ELECTRICAT.PLUMBING-MECHAMCAL CATEGORY CONTROL p
Architect/Engineer. Lk.Na'
QTY' . . ELECTRIC PERMIT FEE 'BUILDING PERMIT INFO
Address:
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE ❑ ❑ ❑
I hereby affirm that l am licensed under provisions of Chapter 9(commen APPLIANCES-RESIDENTIAL - JOB DESCRIPTION '
Ingwith Section 7DUO)OfDiW9=3ofthe ButlnessandProfessionsC e,and my'
Lienee IB In fu A ect. PANELS -
License lsee Llc.N '
D. Contractor UP TO 2DOAMPS
ARCHITECT DECLAR TION 201-1000 AMPS /tea
µq!aa Zp plans se used as public
I understand my hall bremNs. OVERI000AMPS SQ.FT.FLOOR AR)A I s/SQ.FT.
& u Licensed PA femlonal SIGNSELECTRICAL
d'y 6 LOia OWNER-BUILDER DECLARATION - SI'ECIpL CIRCUIT/MISC x -
Thereby afRrtn that l am exempt fromthe Contractor'.License Law for the
6 oZ p following reason.(Section 7131.5,Business and Professions Code:Any city or L'FMP MEI'ERO LE]NST.
r4j, cwntywhichrequlresaper twcomtmc"ter,lmpmve,dem it h,orrepair
ggyy .Qn anystmdure prior to it.issuance,also requimathe applicant lorsuch permltto - POWER DEVICES
I5 C V file a signed statement that he Is Lamed pursuant to the provisions of the '
3w0 Contractoe.License Law(Chapter 9(commencingwith Section 7000)ofDivi-
L,� sion3ofthe Bu.ineas and Profeeslom Code)orthat he ls exempt them(mmand S NG C VALUATION-
yd S the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjectsthe applicant to a civil penalty of not morethaA --
five hundred dollars($50%. NE I RjtlnALEL .FT. STORIES TYPE CONSTRUCTION
41 ML as owner of the property,or my employees with wages as their sole
c°mpensatlon,will clothe work andthe structure isnot intended or offeredfor •--
O sale(Sec.7614,Business and Professions Code:The Contractor's License law
$ does not apply to an owner of property who Wilds or improve,thereon,and
C• who does such work himself or through his own employees,provided that such OCC.CROUP RES.UNITS
Improvements are not Intended oroffamd forsale.If,however,the W ilding or TOTAL:
Improvementissold withinoneyearolcomplmioRtheowner-bullderwlli have
to rd en of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT' FEE FLOOD ZONE APN
n '
Lac owner of the property,am exclusively contracting—11 licensed PERMIT ISSUANCE
'contractors to comtmct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does nut apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
Wilds or improve.thereon,and who.contracts for such p -lnjeea with a, •FEE'SUMINARY
oiR¢actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B'k P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
Q _ N_
I hemby afflrm that I have a certificate of consent FD(LLIRES PER TRAP SCHOOL TAX Yto self-Insure,or - IEC— K
certificate ofWorkxma C--pa—B-Imuran.oracamfled copythereof(Sec. GAS EA.SYSTFT.S-1 INC.401TILE75 PARK FEE Y N-
3800,Lab CJJ ,{
Polity q .L(J/�/rs �0�7 x GAS EA.SYSTEM-OVER 4(EA) RECEIPT If
Com any V /1/O � BUILDING DIVISION FEES
�CertNed copy hercbytthcity
e city inspection division.e
Certified ropy 6 filed with the GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
-
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA p6Ff• Date Recei tN
(Thlaeectlon need not becompleted tithe permit isf°rone hundred dollars
($10))°,less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
performance cerdlythat In the perfounce of the work forwhich this permit is issued, —
I.hall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workera'C°mpenaatbn laws of California. Date PAID `
ZZ Applicant - NEW RESIDENTIAL PIMB. gQ}T. Date Recei t# "
-O N'OTICETO APPLICANT:If,offer making this Certificate of Exemption,you
Fshould become subjecttothe Workers'Compensation provlslom ofthe Labor TOTAL:
T Code,you must forthwith complywlth such provisbworthis permit shall be BUILDING
W > FEE 37
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il I hereby affirmthat there ls a corutmctlon lending agency for the perform ELECTRIC FEE '
Z ance of rhe workfor which this permit is Issued(Sec.3097,CIv.CO TOTAL:
(,) 4 Ichder's Name PLUMBING FEE
IL I— Lender's Address CITY, MECHANICAL PERMIT` FEE MECHANICAL FEE
O 111
lomifythatl havereadthisappliationandstatethattheaboveinformati°n _
M mconect.lagratocomplywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N relating to building comtmctlon,and hereby authorize representatives of this -
L. Z city to enter upon the above-mentioned pmperty for inspection purposes, ALTERORADDTOMECH.
.t Z (We)agree to save,Indemnify an d keep harmless,the City of Cupertino - - Date Receipt#
againsthabilltim,pdgmems,costs an
As
which may in anywayaccme AIR HANDLING UNIT(TO IO,ODO CFM) SUBTOTAL:
agal Id City in conuqu ce o gr ting of hl.pannit.
f Q/ AIR HANDLING UNIT(OVER]O,fl[O CFM) CONSTRUCTION TAX
Sign reof Appill , Contraq D to EXHAUST HOOD tW/DUCT) CONSTRUCTION TAX PAID:
HAZARDO MATERIALS DISCLOSURE
Will theapphcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)' Date Recei I><
terlw as defined by the Cupertino Municipal Code,Chapter 9.12,and the
11'.1t a�d SafetyCode, eLpr✓Li532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
Will the applicant uiMture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
Mich emit hazardous air comamlmnts as defined by the Bay Area Air
(,ua lity Management Dlsm BOILER-COMP QHP OR 100,0(10 BTU)' FAIL)
_ ••,
4 Yea o .
have read dalth a lett'Code,Se ed coni 25505, 5533 aChapter 6,95 of BOILS&COMP(OVFR 110,000 BTU)
the Calent Ad
Health building does
otcu entlyhaveat tenant,nd 25534.
NIAk 05 1y�J.
understand that lithe bullding doe.nut artently have atenanq that ltlsmy NEW RESIDENTIAL MECH. �.FT.
responsibility to not lfy the occupant of the re u iet
s which must be AAA
c an City(1€Cignaffirto
r, eros aulhorieed agent Dae ISSUED BYA s W 1^VC-"
TOTAL:
OFFICE COPY