19909 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
act, Building Address: 19909
.24/L/7
t_nvner.Name: phone: APPU71k A A
CITY OF CUPERTTNO-BUILDING DIVISION
Ca roan:Pqr Lie.No: APPLICATION /PERMIT
U BU7LDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL p
Architect/Engineer. Lic.No:
.QTY ELECTRICPERMIT -FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE I�[ ❑ El ❑
LICENSED CONTRACTOR'S DECLARATION
I herebySection 700 thatl Divisised on
ofthe er Business
lsions and PrfChapter ssions9de,aneme-d my APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Seaion7000)o(DiWsion3ofthe Buslnesand Professions Code,and my
license is in fu I'}cad effect PANELS
License la Y. Lk.a ! U /'Ll/� P(yp
Date Contractor Oy7A,�/ UIIQMQANTq CCC//////... rrr P—Cir
ARCHITECT'S DE ATION / 201-IODOAMPS i
{qqp+±±
9
0 0 1 understand my plan shall be used as public records. IOVERIOD04MPS SQ.FT.FLOOR AREA $/SQ.Fr.
E Z 'Licensed Professional AGNS ELEC AL
<6 w OWNER-BUILDER DECLARATION
jn Fn SPCCIA IRC /MiSC-
p, Thereby a(firmt}utlam exempt fmmlhe Contractorb License Law(or the
OZ 9 t. following reason.(Section 7031.5,Bushes and Professions Code:Any city or TEMP.MPO N
t� cmntywhkhmqui apermitWcomtmd,alterimpmve,demlbh,orrepair
�< any structure prior to its lasuance,also requires the applicant for such permit to POWER
Wap b
U file a signed statement that he is licensed pursuant to the provisions of the
Contnaor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- G ELECTRIC VALUATION
OS sion 3 ofthe But sines and Professlom Code)or that he is exempt therefrom and'
G the basis for the alleged exemption. Any violation of Section 7031.5 by any .� .rc Fl r
applicant fora permit subjectsthe applicant to a civil penalty of net more than
e. five hundred deltas(3500).
I,as owner of the property,or my employees with wages as their soleRESID SQ.Ff.
F-11, STORIES 'E CONSTRUCTION'
compensation,willdothe work,and thestaaure,is not intended or offered for
O .1.&c.7044,Business and Professions Code:The Contractor's Llrense Law
('y � docs not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UMTS
who das such work himself orthrough his own employees,provided that such
improvements are not Intended oroffercd for sale.IQ however thebuilding ee TOTAL:
improvement is sold within oneyearofcompletion,the owner-budderwill have
thAvrden of proving that he did out build or improve for purpose of sale.). QTY. - PLUMBING PERMIT FEE FLOOD/SNE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7044,Business and Protestors Cade:
The Contractors License Taw does not apply to an owner of property who
Wroves ALTER-DRAIN&VENT-WATER(FA)
ilds or Impthereon,and who coramm,for such pW*u with a FEE SUMMARY
cgy(aaorts)licensed pursuant to the Contractors License Law. BAC(FLOW PROTECT.DEVICE
LI I am exempt under Sec. B &P C for this roman
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data RECEIPT
WORKMAN COMPENSATION DECLARATION MTURES PER TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of o' rtified re
consent to self-tnmrre or a - 1
certificate of Workers'CompesaHon Insurance a mcopy theof T.C. RECEIPT
3800,Lab C. /• / GAS EA.SYSTEM-I INCAOUTLETS PARK FEE Y_ N_
Poliry RWEIPT a
Com env L/OY'a_/A✓L� // GAS EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
�Certifled py is herebyth the city
GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK PEE
Certified copy V filed with the city Inspection division.
CERTIFICATE OF E(EM I'TION FROM WO R KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM EA.200FT. Date RCCCI t# '
(this section need not W completed tithe permit isfor one hundred dollars
(s10))nrless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhich this permit Is issued,
1 shall not employ any person In any manner so as to become eubjea to the WATER SYSTE34/TREATING
workers'Compensation laws of Califomla.Date PAID
O Z NOHCETO APPLICANT:If,after makln this Certificate of Exem licant NEW RESIDEN'IEAL Pf.MB. SQ.Ff. Date Remi t#
Z O m ptmn you
should become aubjM to the Warkers'C pcnsatlon provisions ofthe GWr TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed red.
W > mrevoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE Z
Il 1hercbyatfirmthat there is amnslracdon leadingagency for the perform - TOTAL: ELECTRIC FEE
Z ance ofthe work forwhichthis permit le issued(Sec.M97,CIv.C.)
O O Lender'3Name - PLUMBING FEE,,
f Lenders Address QTY. MECHANICAL PERMIT ItFEE;-
LL U I certifythatl have rcadthlsappintionand statethatthe above Information 'MECHANICAL FEE
O W Is cermet.I agree to comply with all city and county ordinances and state laws PFRMITISSUANCE FEESP IFj;
} 0. relating to building construction,and hereby authorlu representatives of this " O �
N city to enter u pon the above-mentioned property for inspection purposes. ALTER ORAD)TO MECH.
_ Z Dale Receipt#•
(We)agree to
s,save,Indemnify an d keep harmless the City of Cupertino AIR HANDLING UNIT(TO 10,000 CFM)
O ago Wtliabllltles,pdgments,comes dexpensea which may in anywayamae SUBTOTAL:
against said City imm�sequenc ft ctingdthlspermit.
MiP L AIRHANDWNG UNIT(OVER IO,000CFM) CONSTRUCTION TAX
Sigof AppBnnt/Contra r r'9 � EXHAUST HOOD(W/DUCT) CONSTRUCTIONTAX PAJD:-
I'mHA7ARD0 S MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNH(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the t�J�
Heaithand Safety Cod, £�Sealprf 32(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: [ DA
n,Yes E319-
Will the a pplinnt or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hamedom air roots minants as dented by the Bay Area Air BAILER-COMP pEm OR 100,IXD BTU)
Quality Maagcmcnt DisWa7 PAID
4Yes L— / o
have read the bozo ourd smalerials requirements under Chapter 6.95 of 1101LER-COMP(OVPR 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building dos not currently have a tenant,that it k my NEW REST DENTIAL MECH. SQ.IT. ( a3 ly`JO
responsibility to notify the occupant of the requirements which at be met
Ari Issuance of a Certifi t of pan
3 6 /Cih� Of Cu)artino
or auth mud ager Date TOTAL:
ISSUED BY:
OFFICE COPY