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19656 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY . , Building Pra'oct Identification I'EILWT NO. RnBdingAddress 19656 -L 6 two F;2- . ante: .Phone: APITICAA CITY OF CUPERTINQBUILDINC DIVISION .4—V- — IT0 Cc i, /SLI=.N : APPLICATION / PERMIT ZX A.4— G! BUILDINGELFCTRICAGPLUMBINGMLCEIAMCAL CATEGORY CONTROL M Archltect/P gineer. Llc.No _ - 4 + + + " BUILDING PERMIT INFO pti''- ELEORICPEAiv11T 1 FEC Address PERhITISSUANCE p LICF,NS D CONTRACTOR'S DECLARATION APPLIANCESRESIDENTIAL - s FOB DESCRIPTION I hereby aftirmthal l am licensed under provisions of Chapter 9(memento Ingwlth Sedion7000)Of Dlvsion3ofthe Bustnemand ProfewionsCode,and my PANELSe license is in full force and effect. Llcense Clae, Lie# - Dale Contractor - 201.1"A PS ARCHITECTS DECLARATION OVER10DOAMPS SQ.FT,FLOOR AREA 5/SQ.FT: " 1qqF±±±O O, s, I understand my pians shall be used as public record - E O Licensed Professioal SIGNS ELECTRICAL - a �Q OWNER-BUILDER DECLARATION SPECIALCE{CL11T/MISC I hereby affirm that l amexemptfromlhe Contractors License Lawforthe (allowing maeon;(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST. . F2t-� county which requires a permit to consbud,alter,impmve,demolish,orrepalr qqq 4',1 ray structure prior to its issuance,also requires the applicant forsuch permit to POWER DEVICES C©� file a signed stateroom that he is licensed pursuant to the prevulons of the Contractor's License Law Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC FFFo G elon3 of the Buslneasand Prommlons Code)orthat he is exempt therefrom and VALUA'DON Ell•-+ the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCT{ESETXTURES ¢S applicant fora permit subjects the applicant to a civil penalty of not more than - ofive hundred dollars(11,500). NEWRESIDENIALELECTR SQXT. STORIES ECONSTRUCTION ❑I,as owner of the pmperty,or my employees with wages as their sole compenaatiogwilldolhe work and thestructure is not intended or offered for , Dsale(Sec.7044,Business and Prefestloa Code:The Contractor's Limnse Law 3$ does not apply to an owner of property who Wilds or improves thereoq and OCC.GRO(11' RIS.UNITS who doessuch work himself ortheaugh hlsownemployees,provided thatsuch Improverreal,arc not Intended oraffered forsale.ILhowevegthebuildinger TOTAL: R 3 Improvement issold within oncyearofcompletion,the owner-bullderwlll have - - - t"rdenofproving that ho,did act build orimprove for purpose of sale.). QTY, +:'.'•PLUMBING PERMIT •t FEE `, FLOOD ZONE APN I_J Las or of the property,am exclusively comms ing with licensed PERMIT ISSUANCE centra a..to construct the project(Sec.7054,Business and Professions Code: + The Contmaore Limnm Law does out apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) Wilds or Impeaves thereon,and who contracts for such p{ojects with a "FEE SUMMARY,-' cffldor( ICE a)licensed pursuant to the Conmidoes License Law. BACK FLOW PROTECT.DEV IJ I nuT.S11317 FITS am exempt under Sec. B&P C for this reason ' DRAINS FLOOR,ROOF,ARRA,COND.. SANITARY Y N Owner Date RECEIPTp M , WORK AN COMPENSATION DECLARATION FIXNRF.S PER TRAPSCI{OOL TAX Y ni N ❑I hereby affirm that I have a certificate of consent to col(-Inwre,or RECEIPT p certiflcateof Workem'Compeaationlaumnce oracertlfed copythereof(Sec. GAS EA.SYSTEMd INCA OUTLETS PARK FEEY •N_ ' 3800,Cab C.) RECTIFY# Policy# GAS EA.5YST fM-OVER 4(EA)- BUILDING DIVISION PEES Com any - - NCertlfiedcopylsherebyfurnished. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE F-1CeZed copy is flied with the city iapection division. ' CERTIFICATE OF EXhW PTION FROM WORKER S' GRFASETRAP PAID ' COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei [1 (This section need not be completed if the permit N for om hundred dollars ENERGY FEE Y N— I ($1 OD)or lest) ENERGY HEATER W/VFM/ELECTR — Immfy that in the performance of the work for which this permit is issued, - 1 shall not emplo any person in any nyoner so as to become subjed to the - NOTICE OWATERSYSIPMMPATING PAID Z WorkersCo cosofCalDatDate _ ,.Remi t# Z ' NOTI t _� 7 NEW RESIDENTIAL PCMB. SQ.R. O NOTICE PU,A (,site ..Pc a (lateis os ofther. Labor shoal came subject to the worker:camps it..provisions ofthe Labor TOTAL: ) Code,you most forthwith comply with such provisions ortbis permitshall be BUILDING 2 > d`rmad revoked. - SEISMIC FEE W — CONSTRUCTION LENDING AGENCY tY' Iherebya((Irmthztthem isetunstrudlon lendingagency(orihe perform - TOTAL. I -lxCo ELECTRIC FEE M Z ante ofthcw.,k forwhiciethis permit is issued(Sce.3097,CIv.C.) _\s PLUMBING FEE V,Q larder's Name - - FEE d" LL ~ Leeder',AddreQTY. MECHANICALPRMIT MECHANICAL FEE O W I certilythat l have readthisapplicatlonand statethat theabove information FEES PAID:' Is turned.I agree wcomply with all city.ed county ordinancesand stale laws PERMIT ISSUANCE } O- relating to building construction,and hereby authorize representations of this N ALTER OR ADD TO MECH. I•' Z city to the an property purpo,e,. Dale RCCCipt# (We)agree to save,Indemnity an d keep eschew the City of Cu perUno againstIlabiWins,}rdgmenb,mrta and AIR HANDLING UNIT(TO 10,0DO CFM)expenses which may In anyway accrue SUBTOTAL: agaiXalyin ne}quence of Ie antlng of this ertnit' CONSTRUCTION TAX AIR IiANDWNC UMT(OVPR IO,WOC[M)SI rant/Contra or Date v MHAUSTHOODM/DUCT) CONSTRUCTION TAX PAID: HAZARDOUS MATE SDISCLOSURE - Willtheapplicantor(uture building occupant store or handle hazardous HEATING UN7T(TO 100,ODO BTU) Date Rccei t#' material as defined by the Cu portion Municipal Code,Chapter 9.1 2,and the -yrs, Health and Safety Codry�-SMlon 25532(a)I HEATING UNIT(OVER 100,000 BMTOTAL: _l ❑Yes I]No yFNDLATIONPAN(SINGLE RESIDI I$$UANCEDATE Will the applicant Or future building occupant use equipment or devices . which emit hazarelousalr mntahnant,a,de0ned by the Bay Area Air BOILER-COMP OR 100,000 BTU) ' Quality Management District? 4Yrs, q No havercadthehu rr D.. ateria6requimmenN.nde,Chaptcr6.95of BOILER-COMP(OVER 100,OW BTU) the California health&Sof Cede,Sedins o25505,25533and 25534. 1 s, understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL ME(7-I. SQ.FT. Clt.r f/ Orton(}IHt) responsibility to notify the occupant of the requirements which must be met - - priorto Issuance of a Certificate Ol Occupancy. Owner or avthorlud agent Date TOTAL: ISSUED BY:'J�..`065' 1 OFFICE COPY