19826 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proles Identification PIR7A7N 19826
Building Address:
P123' h RPA 13 1.1E V;6;7-IX
ners hone:
7_)\Q V_L_F— CITY OF CUPERTIN6BUILDING DIVISION //?O
Ca, doYrName: (asuSSI.; APPLICATION / PERMIT ` `T
-r-1 -r I BUILDING-ELECTRICALPLUMBINGMFLHAMCAL CATEGORY Cj�'f�0
Archaeat/Engineer. Lk.No: Q D
wq
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 1014(D o U 1,7 D V L04V PERMIT ISSUANCE .
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licnsed under provisions of Chapter 9(commeno APPLUNCESRESIDENTIAL JOB RExTION
Ing with Section 7(700).(Division 3ofthe Buelneesand ProfnalonsCude,and my
license Is In fullrose and e((ed. PANELS
License Clan$_Lie N rrl (`.17 Jr /II`�-'•/�'I
Data 2 Cif h Contrado l {x
__ 1 RCHIT.rt pE NZ 201-IODDAMPS
q�+070. Iundentand myplara.luBbe used npublicrecorda OVER1000AMPS SQ.Fr.FLOOR AREA f/SQ.Fr.
Fi E Licensed Pro(enlowl SIGNS ELECTRICAL
GG Ltl`l� OWNER-BUILDER DECLARATION SppLIpLCIRCOT/M 6 T
ft
1herebyaffirmthat lamexempt fromthe Contractoe.License 1.w(or the
7. following meson.(Section 7031.5,Business and Pm(enlona Code:Any city or TEMP.METER POLE INST.
tywhlhrequmapemttocoatmd,ilterMproedeml / O/
05. 00
anystmmmpdort.its LesuancgabomquimstheappBantforsuchper tto POWER DEVICES
file a signed statement that he b licensed pursuant to the provbiona of the
3 n.� Conto,dols License Law(Chapter 9(romnrncingwith Section 7000)ofDiet-
�OS lon3oflhe Buainenand Prose mCMe)or Mathelsemmptthomlmmand SWIMMINGPOOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjMetheapplicamtoa civil penalty Moot mumthan OUTLETSSWHCFESFTXTURES
Ove dollarsr).
/ 6
`
I,as ownerofthe property,or my employees with wages eathelesoleNEW RESIDENTIAL ELECTR SQ'FE
STORIES TYPE CONSIRUCTIDN
C < compensation,will dothe work,f..[. struce: 13 Th.ctmmded License d for
Law
O rale(Sec.apply
Bu siness andf pruparty Code:The uilds or imp eves I hare slaw
whoddoes oessuch torn imserofpnough who namporlmprwvided that and OCC.GROUP RES UNITS
whodoneuchwork hinvseamthrough his ewnempl.yen,providMthatsuch
Improvements a--intended oroffered(oreale.If,horn..,the building or TOTAL;
mr (")
Improveent bsold within oneyearofcompletbry the.wnenbullderwill have D L-
tIlLturcianof pmving that he did not build or improve for purpose ofule.). QTY, PLUMBING PERMIT FEE FIADD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed n PERMIT ISSUANCE to a�1
contredon to conatrod the project(Ser,70K Bualnen and Professions Code: L.Ld/
The Contractor's License Law donot apply to an owner of property who ALTER-DRAIN EVENT-WATER(FA)
Wild.or Improve.thereon,and who contracts (m such p(oJeds with a FEE SUMMARY
c7Vetor(a)Beamed pursuant to the C.ntnedoeB License Law.
L-J I rm exempt BACK FLOW PROTECT.DEVICE OUTSIDE FEES
under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
�ea,� RECEIVE N
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP xw SCI{OOL TAX Y_ N_
hereby affirm that I have a artlfiate of consent to self-insure,or ate.N
Sena. MWorken'ComperoaHoein nnwma"dtfl mpythe=f(Sm. RECCAS EA.SYStTM-1 INC.60UTLErS
3800,Iab C.) • PARKFEE Y_ N_
REC
pws
Cram any GAS EA.SYSTEM-OVER d(EA) BUILDING FEES u
rtlfird copy b hereby furnished.
Certified copy CREASE/NDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
b(Iles with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' C PAID
COMPENSATION INSURANCE - Date RCCej t#
(ThIssedien need na becomplied Rthe permit Is(or one hundred dollars
($100)MI..) Wp /EL ENERGYFEE Y_ N_ �•�Q
I eenifythat in the performance of the work forwhich this permlt is issued, .P. 0
I shall nm employ any person In any manner an as to become subject to the WATER TREATING q
Worken'Compematl..Lamof Callfomia.Data / 4 PAID 'rJ�•`TJ
OZ ApplicantNEW RESIDENTIA Date Recei tN
Z (] NOTICE TO APPLICANT.If,aRn me king this Certificate of Exemption,you
I" should become subject to the Wor4w
ers'Compert fun provisions of the Labor TOTAL:
N code,you=at forthwith comply with such pmoblon or this perrrdt a hall be I G
deemed revoked. IME
W
G CONSTRUCTION LENDING AGENCY SEISMIC FEE /2
lhercby afOrm that there bacomwctlon lendingagenry for the penorm - TOTAL: �(_� ELECTRIC FEE
7 O 'ane o(lhe work(.rwhich this permit b lesued(Sec.3097,Civ.C) a ELECTRIC EEE
Lender'.Name
IL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE �j T)0
O W ImAifyth.tIhave readthb appliatlonand statethatthe above ln(ormatlon
1 ismmot.1agree to comply with all cityand county ordinances and nate laws PERMIT ISSUANCE 2.LT FEES PAID:
>. relating to building conatmdion,and h.mbyauthmilze representatives.(this �r
F- 2 city to enter upon the above) cmentnned property for Impection purposes. ALTQ20R ADD TO MECH. (•� Date ReCei tk
_ (Wagree to save,Indemnify and keep harmless the City of Cupertino
against lablWies,judgments,aunsand expenses which may in anywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.g.Wt said City In--sequence of the Snoring of this permit
MR HANDLING UNIT(OVER 10,lDOCM) CONSTRUCTION TAX
Slgnalu rc of Applicant/Contrador Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or lotion,building occupant store or W Mile hanrd0ue HEATING UNIT(TO 100,000 BTU) Date Revel t>f
material as defined by the Cu penin Municipal Code,Chapter 9.1Z and the
Iiealth and Safety Cod ylon 25537(x)7 HEATING UNIT(OVER 100,000 BTU) T L•
❑YesWill the applicant or town,building oatrpant use equipment or devices VRNTILATION FAN(SINGLE RESID) ISSUAN
which emit harardoue air mntaminxnb as defined by the gay Arca Air yy `7
Quality Management d7 BOILER-COMP(71E'OR 100,000 BTU) 114 ! 5199
❑Yea N,. d
Ihave read the Faz,KN,.
o materblsrequlmmenbunder Chapter G95of BOILER-COMP(OVEBi00,000BTO) 0
the California Health k Safety Code,Sections 25505,25533 and 25534.1 /aa
u Ment rad t lfthe building does not mrrently have a tenant,that it in my NEW RESIDENTIAL MECH. SQ.Fr. V, of ��/aaaaae.��.,,.,,,,aa.��•
rn Ity to nlf!'thIfici prat.(the requirements which mustbertat ��-
�/_•/!l^rzll/re
p' rfh uana Occupancy.
neroVuthooaftlageDate '�k,.� Bk'� ' `[p•��M�-'J
TOTAL; ISSUEDBY.VV�4c'^""--`�
OFFICE COPY _ ��