19479 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prti cat Identification - PERMIT NO.
Building Address: 19479
-/ r 44R � Dila
here Name: � Phone: A A A
�t1^/ ryl�o "CITY OF CUPERTINO-BUILDING DIVISION
contradarawme: _ �jy Lic.No. APPLICATION / PERMIT — C — 71 p�
Q(✓ C `����� _ BUTLDINGELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL)
Architect/Engineer: ^^ Lie.No: J
C.19
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO -
'
Addrcs:Z O /ryQ U�s//J-' (I PERhIITISSUANCE - (� ❑ IP}
LICENSED CONTRACTOR'S DECLARATION .I f(J
I hereby affirm that l am licensed under provisions of Chapter 9(rommene APPLIANCESRESIDENIIAL JOB DESCRIITION
ingwith Section 7000)of Divlsion3ofNellusinessand ProfeesionsCedeand my -
lh,c se is In fu0 Y and affect. t ZZ/dO PANELS
LI D.takh las Uc.N T 4i0UP TO 2DO AMPS
�Ov �
DatR /}N.1 Contractor 201-10DOAMPS
ARCHITECTSDECLARATION OVERID00AMPS SQ.FT.FLOOR AREA $/SQ.FT.
pr,+re0 O I understand my plata shag be used as public reards.
&td11j Licensed Professional _ SIGNSELECTRICAL
f¢W
`!n OWNER-BUILDER DECLARATION
� fB
z i.., Ihereby armthat lam exempt from the Contractor's License Law for the SPECIAL CIRCUIT/MISC
09 foltowing reason.(Section 70315,Business and Professions Code:Any city or TEMP METER OR POLE INST.
rM countywhich mquires a perrrdt tommtrod,alter,impmve,demoilsh,orrepair
¢, anystructure priorto its Issuance,also requireethe applicant forsuch permit to POWER DEVICES
U file a signed statement that he is Bcensed pursuant to the provisions of the -
O t— Contractors License law(Cha er 9(comrencin with Section 7000)o!Divl- VALUATIO �'
y Pf R SWIMMING POOL ELECTRIC
H�O� the bass for the ess alleged
An violation of cimenjuSection herefromany - i�.
a ¢
the basis for thealleged exemption. Anyviolationto a civil
of Section 70315 by any 7 0UTLETSSWITCHESHXTURES yX
fiynh alforapermitaubjecta the appOcanttoa civil pevlry of not more than
a o live hundred dollars(5500).
I as owner of the NEW RESIDENHAL ELECTR SQFT. STOF1 TYPE CONSTRUCTION
�j.. property,or my employes with wages r there sole
>y
compensation.70K
ldess and rl,Pr and the s Code:
h not intended adon'orcense offered Lw
5 t O sale(Sec.7044,Bushes and Professions Code:The ConlradoJs License Law '
- $ does nM apply to an owner of property who builds or improve t hereon,and OCC.GROUP RES UNITS
who does such work himself orthrough his own employees,provided that such ��
improvements (however,am not intended oroffered for sale.If, thebuilding or TOTAL:
Improvement issold within oneyearofcomplNlon,theowner-bu0derwill have -
it den of proving that he did net build or Improve for purpose ofsale.). QTY. - PLUMBINGPERMIT FEE FLOOD PANE AIN
ryas owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 704A Business and Professions;Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM
Wilda or Improves thereon, and who contracts for such pmjecta with a FEE SUMMARY
m ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW IaROT'CCT.DEVICE
LJ I am exempt under Sec. - B& P C for thin reason
OUTSIDE FITS
DRAINS FLOOR,ROOF,A COND. SANITARY Y _ N_
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION FIXTURF_SS PER TRAP 'SCHOOLTAX Y N
hereby affirm that I have a certificate of consent to pytheureora RECEIPT N
cedi,abo(Wmrkeri Compemation insurance ora certified ropy thereof(Sec. GAS EA.SYSTEM-I C.4 ECS PARK FEE Y N
3800,Leis CJ RECEIPTN
__ _ Policy N GAS EA.SYSTEM )
Com any BUIL DING DIVISION FE[5
Certified ropy is hereby furNahed. GRFASE/INDU5 PLANC14ECK FEE
�4 ndied copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GEA I PAID 33y�,0
COMPENSATION INSURANCE 5 Y-STO 2WFT. Date Recei t#
(This section need not be completed If the permit is for one hundred dollars($1f)D)orles.) Wr ]FRw/ /Fl Ff ENERGY FEE Y_ N_
I o rtlfy that In the performance of the work forwhlch this permit is issued,
I shall not employ any person in any manner sa as to become subject to the
Worker'Compensation Lawsof Callfornla.Date W . SYS / G PAID
O Z Applicant !ESI AL PLMB. FT. Date Reeef tIl
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workeri Compensation pmeisions ofthe Labor TOTAL:
(4 Code,you must forthwith comply with such provisioro orthe,permit shall be BUILDING FEE BUD
deemed revoked.
W � CONSTRUCTION LENDING AGENCY SEISMIC FEE •Y
CL e Ihereby affirmthat them iia construction lending agency for the perfarrmTOTAL: ELECTRIC FEE
:) Z ante of the work for which this permit Is bared(Sec.3097,Civ.C.) '
0O Lander'sName Ill - PLUMBING FEE
Lenders address QTY. MECHANICAL PERMIT FEE -
LL U Icertilythat l have read thlsappllation and statethat theaboer Information MECHANICAL FEE et •Uu
W iscorrect.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE 42. o0 PEES PAID: -
u} N relating to bulldingmnstludimn,and hereby authorise representatives of this
I— Z city to enterupon the above-mentioned property for inspection purposes. ( ALTERORADDTOMECH. U O DatC RCCCiIIt4Y
(We)agree to save,indemnify an d keep harmless the City of Cupertino
fJ against liabilities,Judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT DO I O,ODO CFM) SUBTOTAL: 2�
xgzins`id[C I Lor, f he gran mg of this � D
Zy �`' AIR HANDLING IINII'(OVQt tO,IpO CFM) CONSTRUCTION TAX
srgramre rAppBac attar Date EXHAUST HODD(W/DIKT) CONSTRUCTION TAX PAID:
H UR OUB MATERIAL$DISC OSURE -
Willtheappllantorfuture building occupant store or handle haxzrdous HEATING UNIT(TO 100,010 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - y
Health and Safety Coder�Section25532(a)7 HEATING UNIT(OVER 1W,WO BTU) TOTAL:
r7 Yea U No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hacardous air contaminants as defined by the Bay Area Air PAIL)
Quality Management Dislrid7 BOILER-COMP DLII'OR 100,041 BTU)'
Yrs . Sa No . . .. 1�
have read the baxa�rYapa materialirequlmnents under Chapter 6.95 of BOILER-COMP(OVER IDQD00 BTU) I•tV Q 1990
L
licalth&SafetyCode,Smions 25505,25533 and 25534.1at if the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.6Tto notify the occupant of the requirements which must be met ace of a Certificate of Occupa nry. CIr/ D• OlfnOrtiHAhorired agent Date -1 ISSUEDB V s
TOTAL: p. D� —
OFFICE COPY
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