19867 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
BuildingProect Identification -- - PERMIT NO.
Bud
ding ress:
�wnere 19867
Phone:. - p
CITY OF CUPERTIN4IIUILDING DIVISION -
trsctoraNpyr�e Le.No: APPLICATION /PERMIT
BLnDING-ELECTWCAI MUMBING-MECHAMCAL CATEGORY - CONTROL p
Ilect/Engineer. Lic.Nu
- QiY'` ELECTRIC PERMIT' •' FEE BUILDING PERMIT INFO-
Address:
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'SunderDECns ofCh ON ,
Iheh Sc,mo lrmthsllab,Bcenad WB.0 rovlslono(Chapler9(rommen APPLIANCES-RESIDENTIAL JOBDESCRIPTION
IngwllhSMian70y00a)o(DIVINon3 ofthe BuslnnaandPmtealonCade,and my
licenseLlan.Class I ft.�Id�Icep 0 Z71
PANELS.
Date 2F CantrsctorUP TO 2DO AMS
ARCHITECTS DECLARATI - 201-1000 AMPS
X�Q2., I understand my plana shall be used as public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA - $/SQ.FT.
IJ- Licensed Professional SIGNSELECTWCAL 14
-
fn 6 LGt OWNER-BUILDER DECLARATION SPECIAL CR2C T/MLSC
zp, I hereby afRrrn that I am exempt from the Contractor'sLicense Law for the
oo following reason.(Section 7031.5,Business and Pmfmic;ns Code:An ci -r
Wdcounty which requiresa permit to construct,alter,Improve,demolish,orrepair TIMP.METERO [NST.
q� a any structure prior to its Issuance,also requires the applicant for such permit to
6 r�2 r� file a signed statement that he la Bansed pursuant to the provisions of the POWER D -
�0Ow Contractor's Lianee Law(Chapter 9(commencing with Section 7000)of Divi- VALUATION
sion3ofthe Buslnessand Profealom Code)orthat heis exempt therefromand N L EC C -
�' the basis for the alleged exemption. Any violation of Section 7031.5 by any
G applicant fora permit subjects the applicant to a civil penalty of net morethan E SWITC / O t 68
ofive hundred dollars($500. NE REBID L TR SQ.FT. STOW TYPE CONSTRUCTION
[:]I,as owner of the property,or my employees with wages as their sok _
compensation,will do the work and the structure Ism intended or offered for
p
In(Sec.7046,Business and Prefessimai Code:The Contractors Literate Law
does not apply to an owner of property who builds or improves thereon,and -OCC.GROUP RES.UNITS
who does suchwork himselforthmough his own employees,provided that such
Improvements amm intended muttered forsale.'1(howevegthebulldinger - TOTAL: (�
Improvementissoldwithinoneyearofcompletiorytheowner-bulderwillhave 1L,
ttttuden of proving that he did not build or improve for purpose of ale,). QTY, PLUMBING PERMIT FEE FLOOD TONE- APN
L f Ie as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contactors to construct the project(Sec.7054 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon, and who contra for such ptopm with a - FEE SUMMARY
cgR(factor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICELJ I am exempt under Sec B k P C for this reawn
OUTSIDE FEES
DRAINS.FLOOR,ROOF,AREA,COND. SANITARY' Y N
�' Owner DMe RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
QI hereby affirm that I have o Insurance
o consent m opy tnsure,ora RECEIPT M
3800,ate o(Workeme'Compennatlon lmuunna ora artilied mpythereo((Sec. GAS EA,SYSTEM-1 INC4 OUTLETS PARK FEE Y N
300q Lab CJ
Polity If f p
S -
Com any ' a GAEA:SYSTEM-OVER BUILDINGDING DIVISION VISION FEES '
cc
ce¢y is hereby furnished.
71 Certified copy la filed with tM'dty inspection dlvlsl GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID -
COMPENSATIONINSURANCESEWER-SANITARY-STORM EA.200FT. Date Recei t# '
(This section need not be completed If the permit is forone hundred dollars
($100)orlea.) - WATER HEATER W/VENT,/ELLCIR ENERGY FEE Y N
-. I artifythat In the performance ofthewak forwhich thin permit is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
C1 Z Applicant NEW RESIDENTIAL PLMB. SQ.FF. .Date, Rece1 t#
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption you
should become subject to the Workers'Compensation provisions of the Labor - TOTAL:
N Cade,you swat forthwith comply with such provisioru orthis permit shall be BUILDING I
W 7 deemed revoked.
CL o CONSTRUCTION LENDING AGENCY SEISMIC FEE
- Ihereby affirenthat there is a construction lending agency for the perform ELECTRIC FEE,
Z sure of the work for which this permit is Issued(Sec.3097,CIv.C.) TOTAL:
O'O Lender's Name .. PLUMBING FEE
LL I— Lender'.Addrena QTY. MECHANICAL PERMIT UMECHANICALFEE
O WImAifythatlhavereadthsapphatbnandmatethattheaboveinformation
1 is correct.I agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
}N relating to building construction,and hereby autho en repraenlatives of this
Iity to enter upon the above-mentioned property for impaction purposes. ALTER OR ADD TO MECH. Date Reit#
Z c
_ (We)agree to ave,indemnify an d keep harmless the City of Cupertino P
againstllabiB[les,pigments,coats and expenses which may in anywayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
a cat aid Ci inro xyuenn of the granting of this permit AIR HANDLING UNIT 10,000 CFM) CONSTRUCTION TAX
��9�2
'3_/6 -po CONSTRUCTION TAX PAID:"
SSmreo(Appliant/Contracto - Date EXHAUST HOOD(W/DUCT)
((((((////// HAZARDO1S AT ERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
t material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) L'S a.
❑Yes ILct
A"No
Will the applicant odfuhre Wilding occupant use equlpment or devices VENTILATION FAN(SINGLE RESID) I DATE
which emit hacardous air centamioants as defined by the Bay Area Air
ahty Management R ct?NO BOILER-COMP OHIP OR I(q,IXp BTU) . Iv�N/Q 1 6,1990
Q Yea '.luso
IhaderHealth
Safer materialstions cmenh5533 and 25534.
6,95 of BOILER-COMP(OVER 100,000 BTU).
the Californiatand to at if t k Safety Code,Section 25505,2ently 5533 a tenant,and 25534. Iunderaxe
resposuandthat notifyhe the ing doesoccupant of to requirmnts whichthat b Lamy NEW RES7DENUAL'MECH. SQ.FT.
responsibilityce notifytheiate of of the requirements which most be met b
' prior to issuance of Certificate of Occupancy.
Ownerorauthoemd agent Date TOTAL: ISSUED BY: `+"cam 9 `�Il'aVv'�'S•��+
OFFICE COPY