19713 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pra'ee ldemlfleatlon PERMIT NO.
BaMing Addm' 19 713
�04�v5 N- y/1ArT" pvE �G+PFIeTI , CA - IS-Dl
one:
TA-tJ�FM C16"PV(�/1 y CITY OF CUPERTINO-BUILDING DPVISION
Contnlar's Name: LIo Na APPLICATION / PERMIT 1 l�
BUILDING-ELECTRICAL-PLLTMOINGMECHAMCAL CATEGORY C
Archltaa teen _ Lk-No:
p QTY ELECTRICPERMIT FEE BUI DING PERMIT INFO
Addreac�D el _ El 1:1 ❑
PERMIT ISSUANCE e.
LICENSED CONTRACTOR'S DECLARATION
I hereby dfremthetlam Lkermdunderpr WorsofC pter9(mmmmc APPLIANCES-RESIDENTIAL JOB DETRITION
:1dningwlth Secdcm7000)of Dlviaion 3oftheBusinessand ProfeselonsCode,and my
Manx ala fs force and dfed. PANELS
Class Life SJC
Date Cornaor
ARCHITECTS DECLARATION 2014000 AMPS
at Z . f urdentand my phv shag be cared n public reaW s OVER IODO AMPSlf! SQ.FT,FLOOR AREA $/:Q.FT.
F Llanxd Pmfesabvl SIGNS CAL Oaf
/a OWNER-BUILDER DECLARATION SPECIALCIRC
7 F'�a Thereby afflem that lameseonpt front the Contestant'sLietrse law for the
following reason.(Sedan 70315,Bombes Professionse M
and Cady dry or
FW cvuntywhkhrequlreapemdttomns d,alte,,lmpmvc,de=Wh,orrepalr TQdP. RPOL Sf.
anystvdure prurto its iewave,also requiesthe appear for such Femur to CFS
1 file a signed statement that he is licensed pursuant W the pmvlsbm of the
23wF. Contractor's License Law(Chapter9(mmmeneing with Seetbn 7000)of DM- NG
F,�O"..•,]]]1 Wn3ofthe ead Pmfsbv Cdt)orseemptthxfmmaVALUATION
theWatsforth..Ilkgedeemptbv. MyWdatiano(SeRbn707151hyany
appeantfora Femur subjHa theappecant toativll pevhy.fare moretHn
five untl owner of
property,
RESID L SQFC. SMSIM TYPECONSTRIICTION
7 pe sa
owner of the pwork.a or he empksyees with wages sa there m
compensation,wW dotlewort;ansale. ade:1bnot intended oroffered for
�0 resit(Sec,]ON,Buslnea and Profmbv Cade:The Contnaors lJave Law
nasspachtoaaowvrd Pmpertyism,me ploy prwnted thstand
cs^ whodoewchworkhlmseeothwgh Msownemployen,provbedthatwch OCCGROUP RFS.ANTIS
Improvements are not Intended oroHered forsale.If,however,thebullding or TOTAL: -
un'towment usordwithbauyearofcompletlon,the ownrrbulldcrwW Wve rS
tryEkurden afpmdng surae db not build orlmpra.e for purpose af„k.). QrY. PLUMBING PERMIT FEE pl-DOD ZONE APN
LJ I,as owner of the property,am euhulwly dam' ,—Ilaerued
eantactoa to construe the pmjai(Se,7014,Busies and Prodeasbm Cede PERMIT ISSUANCE
The Contractor's license Law doe not apply to an owner a property who
builds or Improve theraon, and who contraea for such M)rdts with a ALTER-DRAINk VENC'WATER( A)
ry➢tCacter(s)ecenaed p.nnunt to the Contractors License Law. FEE SUMMARY
LJ I am oempt under Sec B k P C for this reason BACK FLAW PROTECT.DEVICE -
n DRAINSFIAORRODFA
, REA,COND. SANITARY Y_ N_
Owner Data RECEIPT Y
WORKMAN COMPENSATION DECLARATION FQTlIRFS PER TRAP SCHOOLTAX Y_ N_
❑1 hereby aelrm that I have a cerd9nte of amxnt to self-Iwre,ora RECID'T Y
dmilate&W.rkere Coopvrsatlon insurance ora certifled copy thereof(See. GAS EA.SYSTEM-1 INC,4OUTLEIS PARK FEE Y N
Poliey Y# RECEIPT 4
I dkGAS EA.SYSTEM-DYER 4(EAI
Cam ray BUILDING DIVISION FEES
�Certlfled copy b heed with hehed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHGCK FEE
❑CertNed copy b/lied with the cBY Inspection dWWan. / ttYq
CERTIFICATE OF EXFAIPI'ION FROM WORKERS GREASE TRAP pAJD1+{6-q0 34LQO
COMPENSATIONINSURANCE
pereANCE SEWER-SANUARY-STORM EA.2D Date Remi t# ZOZl
(I'hbacctbn need one W completed dUu permit lsfa ons hundrnd dollen
($1 OD)or lona.) WAMI-EEATFRW/VENT/ELECTR ENERGY FEE Y N
I artuy that In the performance of the work for wMcb this pertNt is issued,
1 shall not employ any peron In any manner w u to become white to the WATER SYSTFMITREATING
Worker:CompensatianlAwsafCalifornia.Date PAID
Applicant
Z Q NOTICE TO MPI.ICANT:If,after making thio Certificate of Esemptbn,you NEW RESIDENTIAL MB. SOFT. Date Reml t#
sbouid become subFct to the Workers'Comperesatlon pnrvlabm of the Labor TOTAL:
BUILDINC FEE F N_ Cade,you mual(orthwith comply with such provbbv or this Femur shall haL-tw-510
W ] deemed revoked.
CL 1] CONSTRUCTION LENDING AGENCY SEISMI FEE • D
I hereby afOrm than thtrt b a mvtwctlon kndbg sgercy for the perform ELECTRIC FEE
7 = anon of the w.Zor whkh this pemut to lowed T+ 309],Civ.C.) TOTAL:
U O L.ender.Name - PLUMBING FEE
LL F lendtra Addreo, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IdoirythatI Wve readthbappBationand state that the abvveinf.r ion
CL hcorrect.l agree to comply with W cfly and county orlinen¢s and sate laws PERMIT ISSUANCE FEES AIP
>. N relaWrg to bulldlog mmtwctlon,and hereby,authob reprQnaHve of this /(� Q
dry to enter upon the abovo-mentlored property for bupectlen purposes. ALTFRORADDTOMECR
Z (We)sgme to save,Indemnify an d keep hermlm the City of Cupertino Date Recel tp
V agaWtllnbWtles,}idgmers,avec..despenaeawhldimayinanywayamue AIR HANDLING UNIT(TO tare..CFM) SUBTOTAL:
agalvt said Clry N ansequence of the granting of this permit. AICON ON TAX
R HANDLING UC(OVER t0,000CF1D
'Signature of Appear/Contactor Date pOLAUST HOOD(W/DUCT) CONSTRUCPION ID:
HAZARDOUS MATERIALS DISCLOSURE Q
WW the app"M or future building ar iuiot store.,handIn hazardous HEATING UNIT CTO IOD,000 BLU) Date Recel tIf
material as defied by the Cuperew Murdpal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATWGIINTC(OVER 100,0008'C[n TOTAL: 19•�
❑Yes Noa
Wllltheapperm tum building occupant use equipment or devim VENTILATION FAN(SINGLE RESOD) ISSUANCE DATE
whkh emit havrd.us ab conamirunts as defleed by the Bay Area Alr
Quality Management Dlstrkt2 BOn.ER COMP OM'OR 10D,00D BTU)
4Ye No
Wveread the F gOuemrte ab requirements uoder Cha pter6.95of BOMEROOMP(OVER 100,000BTU) '
the California Health k Safety Cade,Sections 75505,r-M3 and 25534..1
understand that if the bulldin does nut currently have a tenant,that It is my NEW RF9DENTIAL MECH. SQ.FT
.povlbilHy to naeythe par dthe requlrementswh Wmel
p ortoL uanvdaCertifla ofodu ney.
out .,via eat t TOTAL, ISSUEDBY:
OFFICE COPY