19856 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prn,mect Identification PERMIT NO.
Build ing Add rasa: �' _ 19856
gSA- k �Po r14-
n/a•A/er-) 1 �-� Vh •b.1N.GJ A A A
Sy,Vt>0�-7q' r.•ctic.+'�6c� CITY OF CUPERTINO-BUILDING DIVISION � O
Contr dorQ•�La.Nce APPLICATION / PERMIT
�- �` ` / BLnDINGE ECTMCA PLUMBINGMDCIIANICAL CATEGORY COMROLX
Orchlted/Engineer. Llc.Na -
_ L `` or QTY ELECTRIC PERMIT "pEE BUILDING)PERMIT INFO,,,
AddressVAA. �j u• 4�I�Z_ PERMITIS5UANCE a•00 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afOmnthat l am licensed under provisions of Chapter 9(comment APPI.IANCESRESIDENTIAL JOB DESCRUTION
Ingwith Section 7000)of Division3ofthe Buslne Band Pro(essionsCode,and my
li —�
cense is to fru f. andeffect PANELS
License Claw�I V Lic.p 1977 /1. n.. OO
Date Contractor L W/
ARCHITECT'S DECLARATION 2014000 AMPS
2 I understand my plain shag be use
d as public records. OVER 1000 AMTS SQ.Fr.FLOOR AREA S/SQ.Fr.
MSIGNS ELECTRICAL
Licensed Pro(esslonal
Q w OWNER-BUILDER DECLARATION 7 a 5Q
SP[CIALCU2CUIT/1,115C
Thereby affirm that(am exempt(romthe Cont,actor's License Law for the '
Zp following master.(Section 70315,Business and Prefessbns Code:Any city or
O]I..� county which requires a permit to construct,alter,Improve,deolish,or repair IFMP.MEIEI(OR POLE INS7.
ni
F`��a hnystmrnrre priorto its issuance,also requlresthe applicantfor such Permit I.
Ufile a signed statement that he is Bcebsed pursuant to the provisions of the ''OWER DEVICES -
3uto Contractors Licerse Law(Chapter9(commencingwRh Section 7000)of Divi- SWIMMING POOL ELECTRIC DA11DN
�0� sion3 of the Business and Prefesslore Coda).,that he b exempt therefrom and
G5p7 a,�, the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSAXIlJRES ,Q O
he
for a permit subjects the applicant to a civil penalty of net mare than
"r 0 O five hundred dollars(5500).
I hundred
NEW RESIDENTIAL ELECTR SQ.Fr. STORIES ECONSTRUCTION
� �, property,or my employees with wages as their sole
compensation,will do the work and the structure is not intended o,offend for
Osale(Sec.7044,Business and Professions Code:The Contractors License Law SI
$ does not apply to an owner of property who builds or improves therms.and
e,3.. who does such work himself or through his own employees,provided that such OC .GRPLIP RFS.UNITS
Improvements arc not intended oroffered forsale.If,however,the building or TOTAL:
Improvement bmld withinoneyearofcompletiomtheowner-WflderwW have
th,12urden of proving that he did not build or improve for purpose of sale.). Q7y, PLUMBING PERMIT FEE FLOOD ZO
PE
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 6 VENT WATER(EA)
builds or improvre
es thereon, and who contracts for studs pne
ujeab with a - -FEE SUMMARY '
[III
licensed pursuant to the Contender's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B k P C for this reason
Owner pate DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
re .r a pp(p(n(Eg RECEIPT N
WORKMAN COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent to self-ov PER TRAP SO TAX Y NRECID'f X
ce 'finale of Workers'Compensation Insurance or a endlfed ropy thereof(Sec. GAS FA.SYSTEM-1 INC-4 OUTLETS PARK FEE Y N
3800.lab CJ RECEU'r X
_ P90 y any
C0,3`.244(oaQ GAS -DVEft4(FA)
Com any p eep S.a�S BUILUINC DIVISION FEES
�CedJled copy is hereby famished. - GRGSEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Ceri ied copy is filed with the city ivpedion division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCCI IH
(This section need not be completed if the permit Is for one hundred dollars
ess.
l
($1 W)., ) WATER HEATER W/VENT/ELECR ENERGY FEE Y_ N_
I rear ew.at N the perforrtunce of the work f.rwNch Ws pednit Is iswd,
I shall not employ any person in any manner so as to become subject to the WATER SYSIEhf/TREATIN'G
workers Compensation Laws o(Californla.Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ.Fr. Date Remi t#
NOTICETO APPLICANT: arakingthu Certificate.!Exemptkm,y.0
�Q
Fshould become subject to the Workers ns
Compeation provisions of the Labor TOTAL:
N Code,youmwstfonhwithmmPy aro pe 1 withsuch v Wnsorthis rmitshallbe
LU 7 deemed revoked. BUILDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Thereby affirm rkfor rich construction landingagency Civ. the perform TOTAL: ELECTRIC FEE �, Q
� Z ante of the work for which this permit isLwd(Sm.3097,CIv.CJ
(J O 1<oders Name_Viq�jg PLUMBING FEE
LL r Lenders Address QTY. .MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedirythatl have read this application and statethattheabove Information
iscorred.l agree to comply with all city and county ordlnances and state laws PERMIT ISSUANCE FEES PAID:
} 0. relating to building construction,and hereby authorize representatives of this
F N city to enter u Pon the above-mentioned property for Inspection pis rposea. ALTERORADDTOMECH.
Z Date Receipt#
(We)agree m save,Indemnify and keep vs whiharmlch
the City of a acesen 03o CFM)
V against lUbllitles,judgments,cogs and expenses which nay in any way acwe AIR HANDLING I1M7 Q010, - SUBTOTAL:
against said City in mraaprence of the granting dr 1 permit
AIR HANDLING uNTr(OVER 10,000 CFM) CONSTRUCTION TAX
signamre.r C dor ate EXHAUSTHOOD(w/DUCn 'CONSTRUCTION TAX PAID:
HA ZA OUSMAT 1 SCLOSURE
Will the applicant or future building occupant store or handle haucadous HEATING UNIT(TO 100,030 BTU) Date Recei t#
material as defined by theCupertino Municipal Code,Chapter 9.1Z and the
Healthand SafetyCdr Se Ion 25532(a)7 HEATING UhBT(OVER 100,000 BTU) TOTAL: 3�•S
RIBYes
Ro
IB theappilcant or are building occupant use equipment or devices VEN DILATION FAN(SINGLE RESID) IS§1-k�i�GE.DATE
which emit lueardous air contambants as dented by the Bay Area Air R�/�9Q3
Quality Management Di��`��strrrrrffffjffff�111117 BOILER-COMP QIIP DR IW.IXU BTIn. ..
Yes IgNo
417veread ist Health
materials BOLER-COMP(OVER IW,000BN) (ti�Att 1 s 1990
the
erstan tatifthA dinory Code,
esnotcons7S50S,ve a leant that it
undentandyton notify
the occupant
of t erequire encs which
that it met NEW ftF57DFNTAL MECH. SQ.FT.
r
prior
to Issuanerad i(ytheompant of the requirerrcntawhich must be rrrt �hj Cvn@rtlPO
- prior to issuance.faCedificateo Ocwp
3 LOAD I�('
Owner or authorized rat ate ISSUED Y:— •"•a "&ut
TOTAL:
OFFICE COPY