19646 APPLICANT TO FILL IN INFORMATION WITHIN RED LI XES — USE BALL POINT PEN ONLY
Building Pm'cn identification pERMLT NO,
B.Bdingeddrem: 19646
<r. ante 19 6 4 6
�.
lot 0 '3 CITY OF CUPERTINO-BUILDING DIVISION
Lk.Na APPLICATION I PERMIT ����
BU=NGELECTRICAI nLtMBING- E HAMCAL CATEGORY CONTROL Is'ea'Fsgl"`v. L, Ic N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE , A c Y
LICENSED CONTRACTORS DECLARATION
Ihereby i`ffirm that l am Bcevseiu"mr pro,dma ofChapter9(comunen APPLIANCES BDESC N
IngwBhSoc Ior.7IXD)ol DiW.3oltheBumnosand ProfenalmuCode,and my
Ilot b L,No tk)"and effM PANELS
License lap L ' I�,
Date- ` Ctn l otos KIt
ARCHITECTS DECIARATION 1'1 AMPS
e4Z I understand my plane shall be used a public remtda 1000 SQ.FT.FLOOR AREA S/SQ.FT.
S L
Loured ProfessionalSI^.
< _ a OWNER-BIJILDEII.DECIARATIO.:7 - . SP" C CIJIT/M
I hereby afOr n that l am exempt from the C.Mractor's License�?'-efo,the
00 fulmw reason.(SMIm MIS,Bumneu and Pmfeak,n.Cade:Any dry^ '
F� county which requiresro 'TEMP O EI
a permit to comm,,IM alter,improve,demolish,or repalr ~
aoylrvcture prim to Its Wutrce,.tw rmi
equ 'the appbant for much pemdt to P0WFRD
po Ille a signed statement that he It licensed pursuant to the pmvtsloru of the
O C runctore Ute.La.(Cltpter9(mmmenrlpg whh Section 7000)of DM. SWIMMING POOL ELECTRIC "
30J don3ofthe Budnmandl'rofmbmC e)orthdhebexemptihemfmmard VALUATION
a'`b y.'•.]] the b•eb for the alleged exemption. Any Wdation of Se icor 70315 by any D�SSWDtf�pDpDg� ^1 ��6Y
applicant for.permit atbjecb the appllcant to a efvll penalty of not morethan a
E aa
lh-p,-huulmd dull.W0Q. NEWRESIDEMTALELECIR SQ}T. '
1,as owmer of the property,or my employeesw hwages u their.ole ..y7� STORIES IYPECONSIRUZHON
compensation,wllldothe work,and the mrurtum brat Intended or offend for 'ZO x�`F-all
5" p mle(Sm.7DK Busmen and Professions Code:The Contmdo'.Genu Law
r$ docs cwt.ppty m.nownar ofpmpertywh Wildsorlmprvvnthe.Nmd
whodoessurhwork himselfathwgh hlaownempleyces,prwMMth.tsuch OCC.GROUP RES.UNITS
impr.vcments are not Intended oroffered forsale.If,however,the Wilding m TOTAL; 2
t Improvement L,oMw Int oneyearefournplmbn,the ownerbullderw111 hive _
EuNen of proving that he did not wild or improve for purpose of sale.). OTY, PLUMBING PERMIT FEE
Ll L as owmer of the property,am exclusively comracung with Ilanrd FLOOD ZDNE MIN
contractors to roc rud the project(Sm.7011,Bushes and Professions Code: PFRMITLSUANCE '7 cn
The Contractor's Lke�Law does not apply to an owner of property who 4
Wilda or Improves thereon, and who mntnN for such pIo"wM a ALTER-DRAW&VENT-WATER MA)
or(e)Iaem,,d pursuant to the Contacts&License Law. BACK FLOW PRO=.DEVICE FEE SUMMARY
I sm exempt under Sec B&P C for this recon '
q1I�nrr Date DRAINS PIDOI{ROOF,AREA,CUND. SANIN_
SANITARY Y_ xy`
WOR"AN COMPENSATION DECLARATION RIL�s
�..`-Y_aIf that I have a arHRute of consent to•elf-Iwre,or-a Z � Z��P �- (YD SCHOOL TAX Y N_
H / cenuiate of orkers'Compennatlanlmurance ma artllled Dopy themo((Sec. RrGEB'Ta
3RW,lab CJ GAS EA.SYSI7201-1 WCI OUTLETS PARKFEE Y_ N
Policy l- i l Z S
RECEIPT Is
CAS EA.SYS ENI-OVER 4(FA)
IT Co , K tA�laalh c C BUIL DI NO DIVISION EE ES
IF,
ropy Ls hereby furnished. CREASE/WDUSIRL WASTE EJTERCEPTOR PLANCHECK FEE
I° Certified copy b filed with the dty lmpectbo divlalon.,
CERTIFICATE OF O(EMPEION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gy/pySAMTARY STORM FA 2(IQ,"1. DOIC RCCCI [N
(Ihls.edbnneed not becom loted BtEe permit lemons hundred dollars
,.(Bm)ar1�.) WATERHFAMW/VENT/ELECTR ENERGY FEE Y N
I ceo,leabat b the paAorrnsnte of the wvxk forwhich Rata pemdt b 6sued,
I.haO nor employ any person in any manner m as to become subject to the WATERSYSTINI/TREATING
workcn:ceempep,.tbn l a.&C.LifomDate te PAID -
Pp Date Remi tat
A vont
IZ OZ
NOTICE TomesubCAM:IL o,*e 'Compi.Cene,pro icons mp A you NEW RESIDENTIAL PIb1B. �F7.
ahmld brooms sub
jeer m the Worken'Compewtbn provfebm of the Labor TOTAL
_CC N` Code,You mvat fonhwdh comply with such prwl.bns orthh pemdldWlbeBUILDING FEE C r,
W,> deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.fil that there lea constrocdon le,relingagency for the penortry TOTAL: ELECTRIC FEE
Z ante ofthe workfcr whkh this perms,I.Issued(See,3097,CN.C.)
02 Lendee-Name PLUMBING FEE
LL'~ ' 'Lender's Address QTY. MECHANICAL PERMIT FEE MECHAMCALFEE
O W Iceru(y tags t cmnplN haUckyaaddatyord[he.bovedn Read
1 MAI"t lagreetoromatmwtth and h by ot1orbm lnanm and lablawe PERMIT ISSUANCE (� FEES PAID.
} city toenteruupon
n t constmctbn,kmed prop sty or in rtptio ntatNn of this
F Z tl Me)
thesbovcmmUan d property for inspection purpose. ALTER OR ADDR7 MFGH. sS
(We)agree b cove,BdemNfy an d keep harmless the Clty ofCupertino Date ReCe1pIN
V g4m bWtlees,'ndgmebb ban de.pemeewhldrrcyinanywayamua AIRHANDLINGUMT(I010,0)0CFM) SUBTOTAL:
a -)dCftym ant tinMofthlepe
AIRHAN0L1NGUNTT(OVFRI0,000CFM) CONSTRUCTIONTAX
1 L! '2 ll•F CONSTRUCTION TAX PAID:
I-LAZA
SI o(A ontr.ctm ate FXEIAl1SC HOOD(W/DUCD
' HASARDOUS MATERIALS DISCLOSURE
Will the•ppllunt or future Wilding ar pant more or handle hazardous HEA TING UNIT(TO 100,000 RTU) Date Recei Nl rn
material am dNlned by the Cupertino MuNdpl Code,Chapter 9.1Z and the trn
EkFa�B Ym Safety Core�La.�S�ectloon 25532(a)t DATING UNIT(OVER 100,000 al" TOTAL:
TVdl".."Bard mfumm Wilding omupant use equipment m rf v VENTILATION FAN(SINGLE Romp) ISSUANCE DATE
whkh emit hamrdouialf oentamiraws as de0rad by the Bay Area Air
A1an�emem DLstnct7 ) BOII.ER-COMP OEIPOR 100,0()BTU)
No��
hiW read the ha>aous hkatenab requirements under Chapter 695 of BOILrx-COMP(OVEt 100,OW BTU)
the Glifomia Hesith&SofctyCbde,Sextlom 75505,25533 and 2553/.1
unelenbrdthatifthe Wildln deesnotarrentlyhaveatenanLthatiti,my NEW RESIDENTIAL MECH. SQFT.
rapgmIbWtytoncllfythe pant of the requirements whkh must be met
prim w Wuaroe of.Ceni eofoac patty.
Owner or sutb ag� ate ISSUED BI'T:�+� 'r\OJS+!�a1c+sN-"�("'Jl -
TOTAL:
OFFICE COPY' ' a'