19566 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build) Pro'ect Identification 7 PERMIT W.
Building
gID Add.: 19566
IQ �w
rcrs .mr. one:
CITY OF CUPERTIN6BUILDING DIVISION '�_ 6
�
Cm to/sNa LIc.No: APPLICATION /PERMIT
BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL.
nchimt/Engineer Lb.Na
QTY ELECIRICPERMIT FEE BUILDING PERMIT INFO
Addreu: PEMITISSUANCE ❑ ❑
LIC ENSEDCONTR under pmvhdons
DECLARATION
I Mrby S,ctio 70 that lamlbsnsee ue8"revldonaoffevud.Cd,.dnr AIPPI]ANCESREgINFNTAl BD6O N
Ingwlth5ectbn70D7)of Divl,lon3ofthe Busineseand ProlestlovCude,ud /
D.tliceI.in(u e�yy�efl�O=Y046 PANELS. P
Lia C/h/m7�r�✓U Lie.#
Dat Contractor �(-PG
AACHITECTS DECLARATION IPI 00AM
µq!aO Z2 I understand roy plav,hall be used u public reads. OVER 10110 AMP$ V ISQ.FT. R 5/SQ.FT.
Z[j Licensed professional SIGNS rq .
OWNER-BUILDER DECLARATION SPEC7ALC T/ '
7k, 3 Ihercbyafflrm thatlamuemptfrmnthe CoMracmra Llmnw Lwfmthe
following reuan.(Section MIS,Boniness and Pmfembv Code My city or TEMP.M= R IN
F county which requires a pemdt to construct,alter,Improve,demollsh,arrepnr
�pG any awnumeatenvitahe he is aicenaud pursuant
to the rovia perMte POWER DEV# � I
�O q.O Ne a signed wtement the he b BrevN parwant to the provisions of the
O w Contractor's Uceve Lw(Cha peer 9(mmorenctng with Section 7000 of DM-
30 abn3ofthe&nMessud Profesebns Code)ormn hebeaemptmerNromaM `{MIN E.FI C VALUATION
the basis for the alleged eaemptlon. Any violatfun of Section 70315 by any «UTILET5SwrrCH Is nrDws
y6i appEsntlora perrtdt wbjectstheapp0cuttoa dull pevlty aloof morethan
p.4 ffv (L`
ndmd dollar, .
�.. I,uoweerofthe property,ormyemes
ploycwdu
hwagestheirsole NEW RESIDENTIAL El 9QF7. SIDWLTS TYFECDNML)CIION
�7a compewtlagwilldothework.andmenmctna bort bdended or offeredfor
❑ sale(Sec.7014,Bualreu and Pmkmbv Code:The CaMradots Lanse Law
don not apply to an owrcr of property who builds or improves thereon,and
F+$ whodaeswchwork hlm:Barthrough hlsownemployeet,pmvded that such OCC.GROUP RES UNITS
Improvemcnb ane wl intended ora(fened(m sok.IL however,thebuilding m TOTAL
ImprovementbsoldwWInorcyearofcanplN Mtheowner-b Werwilove
t rdenof proving Nat he did no lnaildorlmprovefmpurposeolsaleJBINC. QTY. RMIT FEE
UI,a owner of the property,am eacluewly contracting with license Fl.WD AI'N
cunt.C.to mnslrud the project(Sec 70,14 �and Professions Cade: PERMITISSUANCE
The Contractor's Lloeve Law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) –Lys
Wiles or irnp.thrmon, and who contracts for.6 pyo}-an with a – FEE SUMMARY
ryD[[ mem
amen(A Ed pususnt to the ContractContractor'. en
License.Lw. BACK FLOW PROTECT.DEVICE LJ I am exept under SB &P C for this m.n
r . Owner Dam DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION - REC�
If
❑I h
,.by affirm the I have a artiflate of consent to self-insure,ase a FOCrURF_S FER TRAP SCHOOLTAX Y N
RECEUq
cedfleam oiWorken'CwnpewR Ivo certified copy thereof(Sec.
GAS EA,SYSTEM-1 NC40ULMS PARK FEE Y N
3803 LbCJ//'' q �j/f —
Policy# CTT7d/ GAS.FA.gYSCFAf-OVER,(ERECEIPT If
Co ny A> - B U I L DI NG DIVIS ION FEES
Certlfled copy b h�re (umWed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�CenNM copy b filed(fled with the city Inspection dMnon.
CERTIFICATE OF IXEMPTION FROM WORKERSGREASE TRAP PAID
COMPENSATION INSURANCE SEIVF.R-SANITARY-SIORAT FA =. Date Recti tic
(I'hlssectionncednabecompinedlfthepemdtbfmomhundreddoflarsENERGY FEE Y N
(g100)or leu.) WATER HEATER W/VINE/F1.FLTR
I comfyn
that In the pedurrna of the work for which Ws pem it is bored,
1 shag not empty any pe,.in any mere,n a to become.abject to the WATEtSYS��M/TRFAnNC IL
Workenawn L
'Cnpetiowsof Cabforia. Date ' PAID
O = Applicant NEW RESIDENTIAL PLMB, 9QFr, Date Recei tic
Z p NOTICE TO APPI.ICAM:H,ager making fhb CenBlala of Fsemptba.you
shmld become wbjct to the Wohere'Compevatbn provbbv of the Lbor TOTAL:
CCN Cade,yw nurt farthwhh comply with such provbbv aNis permit shall be
deertcd revoked. BUILDING FEE
LLI d CONBem Isa ONLENDINO AGENCY SEISMIC FEE
Ihlthe .mrmtn.tthereb.constm a, lending,geruCi forme pedarim - OO ELECTRIC FEE
7 Z oncedthe work( molt's Civ tJ TOTAG
U O tender.Name Kr r -Y!�(/Le Iy PLUMBING FEE _D
H Lenders Address QTY. MEC ERMIT FEE
LL MECHANICAL FEE
OW ]aduythatl h.vercadthbappllatbnard statethnthe above lnforrvtlor --Y4
C iscumcci.Iagreetocamplywhhandtyardmuntyordwna. dnttelawa PERMIT ISSUANCE K–D-V FEES PAID:
�. relating to building construction,and hrmby.umomm representativn of this
1'
� Z buy to enter up..the abovcmmtbrvd Property for Inspection purposes. ALTFRORADDTOMECH. �V Date Rttei tp
(We)agme to save,bidemNfy an d knm
eep halem the City of Cupertino
V agalvt llabWtles,judgment.,co+sand eapevn which may In anywayacvue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: .o'
ID
against old City in consequerwe of the Used Ing of this pemdt.
AIR HA NDUNG"IT(OVER 1(IM CFM) CONSTRUCTIONTAX
&gvturcof Applicant/Contractor Date E(FIAUSF HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCIDS URE
Will the applicant orfuture buflding occupant port or ha cad Le harulous HEATING UNIT(10 103000 Bon Date Rttei t#
mated.)as defined the Cupertino Code,Chapter 9.12 and the
He.hh.rd S.fctyCode Section 35533(.)7 HEATING UNIT(OVER 100,000 BTTn TOTAL:
ILnn Yn ,I+�–,1 No
Ithe applicant�rf m building occupantux equipment or devim VENTILATION FAN(SINGLE RESID) ISSUJe@�BiBt�t(�TE
which ereret harardou,air ostamlwnbas defined by the Bay Arta Air 1�–/gGVJ
Quality Mavgomeer Dbtriti Wes FR-COMP OHNOR 100,W BTU)
My� No
readtheha m smatenabrequlrerrcnbundcrChaplerG95of BOIL C0MP(OVERIm,000B11n JUL 16 1990
the Califmnb Health&Safety Cade,Sections 25505,35533 and 35534. I
urdes Mthatifmebuildingdoesmtmmentlyhaveatenant, titbmy N'EWRESIDENTTALMECHL SQ.FI'. /a,' ,y;
responsibility to sally the oavpant of the requirements which nm
est be et QW of yuPQ"'RO
primtolmuaooeaaCertltlateof Oc paocy.
Owne,aiuthorieed agent Date ISSUEDBY: a
TOTAL: 24,00
OFFICE COPY L