19548 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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.�IaPdingAid.: 19548
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CITY OF CUPERTIN0.BUILDING DIVISION /
APPLICATION /PERMIT
mQ A T Rec&c 56693
BUIIDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
Architect/Englme - Lk No:
a �nGeR BUILDING PERMITINFO
QTY ELECTRIC PERMIT FEE
Add— ygOO EL cAm;.'Io Los )Vos - PERMTISSUANCE .(t8 � � o a
LICENSED CONTRACfOR'S DECLARATION
I hereby affirm that l am licensed under provisions o/Chapter 9(corrunen APPLIANCES-RESIDENTIAL JOB DESCIFE-DON
ingwlth Smibn 7000)of DIWJon3ofthe Busmes.nd Pro/.douCade,andnty
Ibeme bin fuBsr dfe0 I+O/rr PANELS
LimDat C O Co r 6 J J
Dated -yo Corrtra¢or
ARCHITECTS DECLARATIONOVER I AMPS
S
q�q�va NOZ IuMenbrd my phro ghe
sluuadupublic re
c owds OVFRIWOAMPS sSQ.FI.FLOOR AREA f/ .FI.
Eob Licensed Prafea W.tc SICNSELFL]WCAL
GGGG'a-LYA OWNER-BUILDER DECLARATION
71G', � Iherebyaffirmfhat lamuemptfromlhe CnMractori Llarse lawfathe 9sFLIALCEtCU1T/M7SC
following reason.E ctlmr 7W 15,Budnes and Profeabru Code My city or
Fcauntywhlehrequboapem Wmr Malt.,Improvgdemolbl"rrepalr
W3S V< anystrudumprlortoibb meb
,aorequimt eappBcentfmsuchpermeto
POWER DEVICES O-C.j1J
6 ry1 Ilk a signed statement that he b hbru Beenned pursuant to the provof the
�QµF. Contractors License law(C"pter 9(commencing with Section 7000)of Disd-
F EO2 J son3ofthe lhdnesand Prof.W.Cade)orthJ he b exempt there(mm.nd SWIMh9NC POOL ELECTRIC VALUATION
Q ...7777 the bub forthe alleged emmptbn. Any Wdatlon o/Section 70715 by any OU IEMSWRCFESHK[URES
L� a0a appllamfor.permkaubjectetheappllcantt..dvll peroayofnotmorethao
E Iivf hundred dI`�W�DENTIAL EI.ECTR
dWn W00). SQ RIES TYPE CVNSTRUCIION
'9..' Lf Laowner ofthe property,ormyemployeew hwag.uth,trsole
compensation,wllldothe work,and the structure Is not intended or offered for
Oak(See 7061,Buei,..d PkAaaloro Code:The Contractors liana Law
$ do.not apply to an owmr of property who builds or Improve themon,and
whodce.uchwork hlmeelforthrargh hlamvnemplayee,prevded that such p OO_( GROf1P RFS UNITS
Improvemew art not Intended oroffered fasale.If,however,thebuiWing a TOTAL: �4D
Improvement beoid within oneyearofcomplclbo,the own.bullderwlll have
t"rden of proving that he did not bred or Improve for purpose of sale-). QTY, PLUMBING PERMIT FEE
U L e owner of lbs property,am euhudvety�tr+nirg with Ilansed FLOOD ZONE APN
mntadon to contract the pjai(See 70K Burin®and Profenbro Code- PERMIT ISSUANCE
The Contractors Lbeme Law don nor apply to an owner o/property who ALTER-DRAIN kVENT-WATER MA)
or in?.thereon, and who contact for such plojecb with• FEE SUMMARY
cop((+ctr,14 Bernal pursuant to the Contractor'.Lite.Law. BACK FLOW PROTECT.DEVICE
0I am exempt under Sec B k P C for this reason
OUTSIDE FEES
Owner Date DRAINS.FLOOR EA,ROOF,ARCONE). SANITARY Y_ N_
• REC
WORMAN COMPENSATION DECLARATION
�atf KEN - �,
C91 hereby affirm that I have a mdlRate of content to uR-Inure,or a FDC UR6S PER TRAP SCIID TAX ' RELEIPI'N
aaNate of Workeri Compematlonleauance a aostBked ropy thereof(Sec. , GAS EA.SYSIFM-t INCA OUTLETS PARK FIE Y_ N
3800,[ab C.) Rpcplfr'
PalkyN 711 WC 507 7tI `000. GAS.EA.SYSTEM-OVER4(EA)
Com BUILDING DI VISION FEES
Certified copy b filedwfumetry, GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CertlOed ropy b(Bed with the dry,Inspection division.
CERTIFICATE OF EXFAIPDON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gE}ypR SANITARY SCORM EA 7(IllPf Date Rcael t#
(Ihb rection need not becomplied lithe permit b fa oro hundred doBus
($100)or tem) WATER TiFA.fErc w/vENT/o,EcrR ENERGY FEE Y N
nes
I ifyfhat in the pedm
ounceof thm
ewk brwhlch thle pemdt b Wued,
I shall not employ any peeoi lo anymanner so u to become subjxi to the WATIA SY I/TRFATING
Waken Com,nuatbn Laws.f Callfonb.Date PAID
0 = Applicant p�you NEW RESIDPNTTAL PL.MB. SQ.FT. Date Reuel t#
Z O NmldbTQmboAPPLICANT: saerm'Compeio trtproviate lonsoftheLabo
should become ub}M to the Worken'Comperoatbn provbbro of the Labor TOTAL:
CC W Cade,you mart forthwith oarnply with such proWsom or this permit shall be
WQ deemed revoked. BUILDING
CL 25 LENDING AGENCY SEISMIC FEE
Iherchy.lnrm that thea ba mrobudlm lending agency for the perforiry TOTAELECTRIC FEE ,
7 Z ante olthe workforwhkhlhb permNbb+ued(Sec 3097,CIv.C.) L 3 0
Q O. Lender.N. PLUMBING FEE
LL 1— lender.Ada,,. QTY. MECHANICAL PERMIT FEE
O w Iartlfythatl have read thb.ppBalbnaM ants thatthe abweln(orrtudon MECHANICAL FEE
1 Etconoct.l agree to comply wbb all ety,and county ordltunm and sate laws PERMITLSSUANCE FEES PAID:
>_ relatingtobuldingmmtructlon,and hereby autho Lm mpneeotatWo ofthb
F Z dry to enter upon the abcv nnenfloud property for bapextbn purpoas. ALTFRORADDTOMFC11. Date Recti tit
(We)agree to save,Indemnify an d keep hamdm the City of Cu pertima - P
V against ItabihUrs,ydgmew,costa.rad e,,pem.which may In any wayaccrun AIR HANDLING UNIT ITO 10,0)0 GEM), - SUBTOTAL: , -
agaimtllulkdC4 con euge dthe�g�nnting dthln permit AIRHANDWNGUNTf(OVFR10,000CFV) CONSTRUCI70NTAX
Sigmtuma/Appmm/C odor Date D(HAUST HOOD CIV/DUCT, CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI SCIOSURE
Will the a ppilam or f.mm building oavpart more or ha M to ha arciou. HEATING UNIT(7O 1W0,0)0 MID Date Recei tit
matertil as defined by the Cupedlw Municipal Code,Chapter 9.17,and the
He❑.Bh.rd Sdety Cod Semon 75537(,)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
WYe � VENTILATION FAN RESID)
filmic a ppliama turnbunant,.capant use equipment.devises I$SVA4ffATE
whicheMthavaNWsairriet? mob a.defined by 1M Bay Arta Air 1("1a-\)'I(�
• Qua ltly hfamgemcrd Dbtrkt7 BOILER-COMP DkB'DR IfXkO[q BTU)
Ya No
have-read the hav�uus materhab requbnrrcnb under Chapter 6.95 of BOTLER-COMP(OVER 100,000 BTI) JAN N 3 h_6J
tlu Califonla Health 4 Safety Code,Sections,75505,ZSSD and 25536.I
un!mtasd that ifthe building don not currently have a tenant that it b my NEW RERIDDHIAL MECH SQFT.
repamrbelty to notify the oavpot of the requirement,which must be met ON of rrlD.,s.1
prior to Lauanc,of.Certificate of Ompaocy. -r I IRO
Owners authatr.agent Date ISSUED BY:�• �-
TOTAL,
OFFICE COPY