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19794 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY Building ProMct ldentifWticn PERMIT NO. Building Address: 19794 zss 3 7yy nen came: phone: =AATE ftZ IL( CITY OF CUPERTINO-BUILDING DIVISION .,..���,�QO tractor's a LIc.No: APPLICATION I PERMIT 1 - / '� � z BUILDINGELECTRICA4kUMBING-MECHANICAL CATEGORY CONTROLp Mtect/Engineer: SO wNo: C CBUILDING PERMIT INFO QTY ELECTRIC PERMIT FEE Address: LICENSED CONTRACTOR'SDECLLA TION PERhBTI55UANCE 1:1 ❑ ' 1:1T hhereby affirm that l am Bcensed under provisions of Chapter 9(exammewc, APPLIANCES-RESIDENTIAL IOD DESCR,II��-lI-ONS_ (/•( InenseiSection 7000)of Dloffect o(Ihe Bupneuand ProleulonaCode,and my fy�" - 1 - _license la in = defeat. PANELS "IWe�Va'WIaL/+ License Clam Contractor 6 -' Date Contractor ARCHITECT'S DECLARATIO 201-1000 AMPS p�p�uu W;. I understand my plane shall be used as public records. OVER IODO AMPS SQ.FT.FLODR AREA $/SQ.FT. Licensed Professional - SIGNSELECTRICAL <<� OWNER-BUILDER DECLARATION SpECIALCEiCUIT/MLSC Zt, Iherebya(Rrm thatl amexempl fromthe Cortmetur'e License Lawfathe q❑ following recon.(Section 90315,Budneu and[hofeulans Code:Any city or Fcountywhich requires a pemNt to construct,alter,Improve,demolish orrepair TEMP.METER OR POLE INST. '1� aoystructom prlractato Its Wuance,alsorequlrestheappllcant forsuch permit to POWER DEVICES C file a signed statement that he b licensed pursuant to the provisiom of the , 3µi. Contractors License Law(Chapter 9(commencing with Stolon 7000)of Divi- SWIMMING 1- 0L ELECTRIC 1 4717 LUATION OJ pon3o(the Business and Profesalons Code)orthat hela exempt therefromand <] the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXIDRES r-'-' O appliantfma permitsubjecte the applicant to a civil penalty of not..the. o R five hundred dollars(5500). ❑I,as owner of the property, NEW RESIDENTIAL ELECTR SOFT RIES TYPE CONSTRICTION p ork,a or my employm with wage r there wk 7< compensadon,willdothe workandlheetrucwrebnot Intended or offered for O sale(Sec 7044,Bwineu and Professions Code:The Contractors Llama law $ dare net apply to an owner of property who builds or Improves thereory and OCC.GROUT' RES.UNITS who does suchwork himself orthrough his own employees,provided that such - Improvements are not Intended oroffered for sale.If,however,thebullding or TOTAL: I ImprovemenMeeold within oneyearofcompletlorytheowner-bullderwili have ' tlig.Ilurden of pmving that he did not build or Improve for purpose of ale.), Cry. PLUMBING PERMIT FEE u L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN contractors to doestruct the project(Sec.7044,Business and Professiores Cade: PERMITLSSUANCE The Canmectoes License Law does not apply to an owner of property who ALTII4ARAIN&VENT•WATER(EA) beefids or improves thereon, and who embrace.for such p(ojMs with a FEE SUMMARY cgalpador(s)Bursted pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE UI am exempt under Sec. B&P C for this reason OUTSI DE FEES DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT N WORKMAN'COMPENSATION DECLARATION FIXTURE-PER TRAP SCHOOLTAX Y N_ F11 I hereby affirm,that I have a certificate of consent to self-Inaure,a a RECEIPT N S certl0cateofWorkere'Compensatlon lnsursnu on artifled copythereof(Sec. GAEA.SYSTEM-1 INCAOU-METSPARK FEE Y N_ RECEIPTIf C.I1ryN GAS EA.SYSPEM-OVER4(FA) - Cm an / BUILDING DI VISION FEES oCDCertifiid copy b hercbyturnla CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE ❑Certllied copy V filed with the city city ty Inspection division. , CERTIFICATE OF EXL-MPTION FROM WORKERS' GREASE TRAP PAID COMPENSATION INSURANCE SEWER-SANITARY-SIURM EA.200FT. Date RCC21 tJl (This section need ma be completed if the permit Is forone hundred dollars (81I(crrlesa.) - WATER HEATER W/VENT/ELECTR ENERGY.FEE Y N I cert Ines.)t In the performance of[he oak for which this permit is laevM, r I shall not employ any person In any manner so u to become subject to the Worker WATIR SYSTEM/TREATING Compensation Laws of California. Date PAID - Applicant Applicant Date Recei t# Z Z NOTICE TO APPLICANT:If,after uWng this Certificate of Exemption,you NE'WRESIDENTIALPLMB. SQ.FT. F O n should beeore subject to the Worken'Comperwtlon provisions of the Labor TOTAL: tl3 Cod,you most forthwith comply with such provisions or this permitahall be BUILDING FEE W > deemed revoked. CONSTRUCTION LENDING AGENCY SEISMIC FEE L d C Ihereby afRrenthat thea lea construction lendingagenry forthe perform TOTAL: ELECTRIC FEE Z anceofthe workforw),lch this permit la issued(Sec.3097,CIv.C.) V O Landers Name PLUMBING FEE IL F Lender's Add., QTY. MECHANICAL PERMIT FEE MECHANICAL FEE U Icertilythatl have need thisappliationand starethattheabove information W lamrrect.l agreeto complywith all city and county ordinances and pate lawn PERMIT ISSUANCE FEES PAID: 4 relating to building construction,and hereby authoram representatives ofthb � city to enter upon the above-mentlumd property for inspection purposes. ALTER ORADDTO MFCH. (We)agree to save,indemnify andkeep the City of Cuperfloo Date Recei t# ."But liabilities,pdgments,"sand expenses whichmay In anywayaccrue AIRHANDLINGUNITUO10,000CFM) SUBTOTAL: ei tsald City co en aafthegraming ofthlepermit 914PAIR HANDLING UNIT(OVER lB,mocFM) CONSTRUCTION TAX 41 'Ig turerf Applicant/Contractor Date, EXHAUST HOOD(W/DUC) CONSTRUCTION TAX PAID: HA2A RDOUS MAMA SURE Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTU) Recei t# -dal as dented by the Cupertino Municipal Code,Chapter 9.1 2,and the IRA � HEATING UNIT(OVER 100,000 BTU) It and Safety Cad JNo 25532(a)7 TOTAL: Yea No VENTILATION FAN RESID) I the aiteard us air town,refusal. asc part allrud by eclulperthe Bay Areart devices I 11 K 1 S NCE DATE Iri'd it havarscusairrict? arab as defined by the Bay Arca AU mgemunt DiaWct7 BOR.FR-COMP OF1P OR 100,000 BTU7 �Noad the hue ua materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU) GO riinp��n la Health&Safety Code,Sections 25505,25533 and 25534.1 that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFIifty to nilly the ompant of the requirements which must be ret �cuanceofaCertlfkateo(Oaupanry.authodred agent - Date TOTAL: ISSUEDBY: s+o� OFFICE COPY