19649 (2) APPLICANT TO FILL IN INFORMATION WITH IN'RED.LINES -USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Enticing Address: -
o �� - .,G-t . . 196:49
vers ams: -
T1�. ` CITY OF CUPERTINBUILDING DIVISION .
I`�S3�Tz. t PPE1J d�
cont Name: ue Na: 4APPLICATION / PERMIT,. - --qO
Arc lect/• ser. 'CLI BUILDING-ELECTRICAL-PLUMBING-MECHANICAL, CATEGORY CONTROL p
Lic.No: t'
- x QTY g'�.„ E�:BCTRIC PERMFI' , ga(i;''}tiCE tt4 x '``"x't BU7LDING:PERiNIT INFO,`,' -
Addreas: PERMIT ISSUANCE x' ELUCI PLUMB
LICENSED CONTRACTOR'S DECLARATION' - F, „ L ,
I hereby af..an I l am licensed under provisions of Chapter9(rommenc- APPUANCESRESIDENTIAL ]Og DESCRB-1 ION
Ingivlth5ectlon 7000of DlWaon3 ofthe Busineseand Professions Code,and my - - - '
license is in full!ores and effect. : - t _ PANELS - [j
License Chs. Lin#
Date Contractor LMIQ200ANTS
• ARCHITECTS DECLARATION 701-1000 AMPS
�Q I understand my plansahall be used as public record. OVER1000AMPS SQ.FF.FLOOR AREA S/SQ,FT.
fb z _ Licensed professional , SIGNS ELECTRICAL -
, OWNER-BUILDER DECLARATION SkCIALCIRCUIT/MISC « P
zp � Iherebyafermthat l am exempt from the Contractor's License Law for the - -
OZ following mason,(Section 7MI.5,Business and Professions Code:Any city or TSP.MP.TIR ORPOLE(NST. -
K t'� countywhich requiresaper twcom=ct,alter,impmve,demollsh,orrepalr ,
q .n any structure priortolta Issuance,also requires the appBant for such permit to .,
LLG°O F Ills a signed'statement that It Is 8anaed pursuant to tM provtslonn of the POWER DEVICES
.Contractor's Llcenselaw(Chap[er9(comrnenemg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
elon3ofthe 8usinosand professions Cade)orthat he lseFaa therefromand VALUATION
the baste for the alleged ezemptlon. Any violate
of Section 7031.5 by any OUTLETSSWI7CHESFIXTURES
uppVanl(ora permit sublade he applicant too civil penalty of not nnrethan - '
fi hundred dollars($500. NEW RESIDENTIAL ELLCTR
j 2 ❑I,
as
owner.of the property,or my employees with wages as their sole 90 FT STORIES TYPE CONSTRUCTION
compensation,wllIdothe work endthe structure Is ha intended or offered for
ale(Sec 7094 Bu."I'and professions Cade:The Contractor'.License Law
$ does not apply to as owner of property who builds m improve,thereon,and
whodceseuch we,khimself a, tough Wemv playee,,provided thatsuch OCC.CROUP,+' RIS.UNITS
improvements amn t intended arotferedfm.ale,I(,however,thebuildingor TOTAL - - (7 �� '
Improvementissoldwithln oneyearofcompldion,theownerbufiderwilih a E�
th�kurden ofpmving that hedid not build or Improve for purpose of sale.). Q]Y +} ;P.LUMBING.P RMI°(=- ,S t «,iFEE „ FLOOD ZONE APN
LJ L as owner of,the property,am exclusively contracting with licensed PERMITISSUANCE
..trade.to consract the project(Sec.7044,Buebiess and Professions Code:
The Contractors License Law time not`apply to an owner of property who -DRAIN&VENT-WATER
• builds or improves thereon;and who contracts for such p4olects ALTER
with a fEA) ,
c,,RRt{{actor(.)Vesnsed pursuant to the Contractor's License Law.'. lt
exempt under Sec. B &P'C for thin mason BACK FLOW PROTECT.DEVICE 'FEE'SUMMARY' -',=j`y.=«,•'
•-LU I am '
Date•.
Owner " DRAINS FLOOR ROOF,AREA,COND. SANITARY Y - N- ,
WORKMAN COMPENSATION DECLARATION RECEIPT#F! TURES PER TRAP Sp;00LTAX Y._ N_
❑i hereby afllrm that I have a lrt cone of consent to doped emu ,ora RECEIPT
380 ceAi,abofWorkera'Compensatlonlnsuance orarertitled ropy tAereo((Sec. GAS EA.SYSTEM-1 INCA 0UTLEFS "
' 38(q,Lab C.) � PARK FEE Y N
Poll If
cy I2ECER'f p ..
Com any GAS EA.SYSTCM-OVER4(EA) ,BUIL DING DIVISION FEES
an
ropyts thereby mrntehed. GREASE/INDll$TRL WASTE INTERCEPTOR PLANCHECK PEG '
❑Cert8led copy i,filed with the city inspection divieloo. ..
'i CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP - PAID
c 'COMPENSATION INSURANCE •Date „ Remi tg
LQh3s,ection need not be completes If the permit is(Drone hundred dollars SEWER-SANITARY-STORMEA.200FT.,
($10])orfe v.) WATER HEATER W/VENT/ELECTR ENERGYFEE � Y ' •N
Icl not rtify that hi
any performance In ottheworI se as whichthispermit is Issued, —
L.hell not employ any Person In ny,manner w cue m becony sub'C to the WATERSYSTEM/TREATING.
Workers Cp Ion aw. C ifomla. Data�� - _ . 2 4 Cly PAID
O Z APPA=ante. Date •Reoei W
Z O NOTICIY[OaAsIsLLCANT.]ya mak tints Certificate of Exemption,you NEw RES1DENTLIl#LMB. SQ.FT.
should become subject to the Worke ompereation provbiam of the Labor - TOTAL:
N Code,you must forthwith romply with Inch provlalons at this permit.hull be .
> deemed revoked. - BUILDING 'E '
LU
"CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency forthe perform- as�/ ELECTRIC FEE
Z ance of the work for which this permit is'taned(Sec.3097,Civ.C.) " TOTAL yI+ C6 '
O O Lanae,°Name -' , - - PLUMBING FEE
LL H LenaeriAthatIh QtY.",t•, MECI-I_A[31GA41PERMIT+ ^•PEE MECHANICAL FEE I `�
O W ]esnifythatlhave readthisapplicationandstatethattheath cinformation - - '
C Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID: '
} tn relating to building construction,and hereby authorize representatives of this
H Z, city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH, '
— r ,.(We)agree to save,Indemnify and keep harmless the City of Cupertino Date ReceiptN'. -
against liabilities,judgments,mrte.rd expenses which may In any wayaceme ' AIR HANDLING UNIT CFO 10,000 CFM) ` SUBTOTAL:
against. , CI In conscryena .granting of this permit" .
/3 Alp
AIRHANDLINCUMT(OVER10,pp CM, CONSTRUCTION TAX -
of AppBant/contractor Date ,, EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
a HAZARDOUS MAT .LS DISCLOSURE �+ry Rth
Will the appllant or(umrebuilding occupant score or handle hazardous. ' HEATING UMT(T0100,000 BTU) Date w«e Re[oi [N
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 75532(,)7 HEATING UMT(OVFIR 100,000 BTU) v=- � lLy�
❑Yes I]No f' i TOTAL:-t L
Will the applicant cantuturcbuilding occupant use equipment or devices VENTILATION FAN ISINGLE RESID)� I$$UANCG DATE
which emit hazy rduus air contaminants as defined by the Bay Area Air - -
QualityManagementDistrict? + , - BOILER-COMP(3HPOR100,0WRT[n " �i1�'f f, ^ll^ap}lq
Ye, nF�No
4havereadlhehaza7ousmatetlaarequfrementsunderChapter6.95of BOILER-COMP(OVM100,000 BTU)
the C lifomI.Health&Safety Code,Sections 75505,75533 and 25534.I'
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff.
responsibilitytonceltytheocmpantoftherequlrementswhichmustbemet
prior to imuance of a Certifiate of Ompancy. '
- Owner or authorized agent ISSUED 6Y: V(A—
TOTAL:
OFFICE COPY
i ,