19508 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'et Identification PERMITN'O.
Building Address: 19508.
wners ame: Phone:
A A A
CITY OF CUPERTINa BUILDING DIVISION p '-
Contnctor'sNane: LIc.No APPLICATION / PERMIT ' 1 —1 b l D
BUILDING-ELECTRICAL PLUMBINGMECHAMCAL CATEGORY CONTROL p.J O✓O
t /Engineer Lie.N.
-
z_ - QJ QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
AdPjj,A Je A J PERMITI5SUANCE
LICENSED CONTRACTOR'S DECLARATION ]
I hereby affirm that l am licensed under provisions ofChapler9(commeac. APPLIANCES-RESIDENTIAL JOB DFSC ON
'ngwithSedion 70M)of Divislon3oftheBusinessandPmfessionsCode,and my -
Iicenex isle full f.me and effed. PANEL9 f I
DateSClam Licp 0 0 � ,II . 1 ^'
Date—Contractor A + "V (/ (W` �Y. TILL
ARCHITECT'S DECLARATION 201-1000 AMPS All
Om ZO I understand my pia. g shabe used as public reoorda JOVER 1000 AMPS 11 tAl i. 1 N SQ.Fr.FLOOR AREA �a$/SQ.FL.
R 6 0 Licensed Professional SIGNS ELECTRICAL N �, 21 11 V 3 -30 . S--
<Zw OWNER-BUILDER DECLARATION &I-1 �,� 1
1n Fn SPECIAL CIRCUIT/M
Ihercby afRrtd
n that lam exempt Contraoh License Law for the pp
followleg reason.(Section 7131.5,BusinSffi and Professions Code:Any city or tEMP.MEIFRORPOLE INST. p '
county which requires a permit to construct,alter,improve,demolbh,or repair 11 1°
�4¢ anystructure prior to its Luvance,also requirestheapplimat for such permit to WER DEVICES n,t'
U file a signed statement that he,is licensed pursuant to the pmvi urn,of the
04 Contradoh License Law(Chapter 9(commencin with Section 7000)of Dlvl- 9Fa
L`i B SWN4MINC POOL ELECTIIIC
3 0 thesiobasis for
the alleged exemption.
Professions Any viothat lation f Seem therefrom and _ VALUATION.D
Sn the basis for the alleged exemption. Any violation of.Ity 17031.5 by any O E7S6WITCHESITXTUIiFS ---
« five hundred
apermi($500). , applicant ton civil pnnalty of na rrorethan
35:five hundred dolUrs(SSW). NEW RESIDENI7AL ELLCTR SQ.FT. STOIUW TYPE CONSTRUCTION
F-1 1,as owner of the property,or my employees with wages as their sole
compensation,wiildo the work andthe structure is not intended or offered for `
5 q sole(Sec.7654 Business and Professions Cade:The Contractors Llcerue law
N�S does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES UNITS
whodoessuchworkhimselfurthrough his own employees,provided that such \
Improvements arc not intended proffered for sale.I(howeveq the W ilding or TOTAL: 0 0'
improvement Lssold within one yearofcompletiom the owner-bu IMer will have
mc� nlcaof proving that he did not WHdorimproveforpurposecfsale.). OTY. PLUMBING PERMIT FEE FLOGDZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sm 7044,Business and Professions Code: 2�0
The Contnctor's License Law does net apply to an owner of property who ALIIILDRAIN&VEM-WATER(EA)
Wilds or Improves thereon,and who contracts for such plojwts with a 'U FEE SUMMARY
to,Ill(ador(s)licensed pursuant m the Contractors License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B&P C for this reason
OUTSIDE FEE—ES
OwnerDate DRAINS EA,FLAOR ROOF,ARCOND. SANITARY Y N_
RECEIPT R
WORKMAN COMPENSATION DECLARATION / F1XTl7RES PER TRAP U� SCJ{OOL TA% Y_ N -
❑1 hereby affirm that I have a certlRrate oLconsent to self-inwre,ora V �� RFCEIPT i—
ce nifimteofWorkens Compereationlre mnceoracedifk mpythemof(Sc. ' GAS EA.SYSTEM-1 INCA OUTLETS 1,00 PARK FEE Y N..
3g W,lab C.) BBC=p
Paltry p EC
GAS F.A.SYSTEM-OVER 4(EA)
Cam any flU1LDINC DI VISION FEES
Certified copy is herebyfurnished.the city
GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE'
Certified copy t9 filed with the city I.petWn division. 163.LIPCERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRM PAID / -
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Reeei t#
(Dissection need net be completed ff the permit Is forone hundred dollars
($1W)orlesa) WATERHEATFRW/VENT/ELECTR OU ENERGYFEE Y_ N_
1 certify that In the performance of Ne work forwhich this permit is issued,
I.hall not employ any person in any manner m as to became,subject to the WAT02 SYS[EM/TREATING
workers'Compensation laws of California. Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.FI'. Date Recej t#
Z O NOm
TICETOA)TLICANT:If,aher zko
ingthis CertiRteof Exemption,you
should becomsubject to the Workeni'Compersation provisions ofthe Labor TOTAL: ee---�'ff
CC7 e Code,you must forthwith comply with such provisions orthb Permit shall be BUI ING FEE JaC•v
deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il IherebyaffirmthatthereIsaco.tructionlendingagencyfortheperform- TOTAL: ,0E TRIC FEE 3 ,O9
Z armed the work for which this permit is Issued(Sec.3097,Civ.C.)
00 Iender11
3
LLI- Leder.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 0-01
1evrify that l have read this applicationand statethat theaWve Information
O W
1 6rormct.L agree to comply with all city and county ordinances and state laws I PERMLTLSSUANCE I�:VD FEES PAID:
>_ 0. to building construction,and hereby authorize representatives ofthis
N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH. -
? (We)agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
V againsthabllities,jedgments, nd expenses which may In anyway accrue AIRHANDLING=(TCI0,000CFM) SUBTOTAL:
antis of this permit.
_ AIR HANDLING UNIT I0,000C ) CONSTRUCTION TAX
Sig. !Applicant/Cont r Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAx P1lI D:
HAZAR USMATERIALSDISCIASURE !-C7 7
Willtheappliant or:01 building occupant store or handle hazardous HEATING UNIT(TO I W,0008TU) 9. 0E Date Recei t#
material as deft tied by the Cupertino Municipal Code,Chapter 9.1 2,and the -
I lealth and Safety Code Section 25532(a)? HEATING UMT(OVER 100,00)BTU) TOTAL:
❑ YSs M No -
Willtheapplicantorfuturebuildingoceupantuseequipmentordevices Z VENTILATION FAN(SINGLE RE-SID) O ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management District? BOILER-COMP(311POR 100,000 BTU)
Yea �1 No �"'oFRP.F,y'
•
Ell Yea
read the bazar7i ous materiab rcquircmcnb underChapter6.95 of BOILER-COHP(OV[R 100,000 BTU)
the California Health&SafetyCode,Sections 25565,25533 and 25534. 1 11 :t y lu9U
understand that if the building does not currently have.meant,that it is my NEW RESIDENTIAL MECFI. SQFI'.
responsibility to notify the occupant of the requirements which must W met
prior to Issuance of a Certificate of Occupancy.
Owner or awhorimd agent Date TOTAL: •7 T,e/ ISSUED BY:
J V
OFFICE COPY