19744 APP[ (CANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'en Identlfkatlon Pk]UOT NO.
Building/dd ss, S 19744
rc e ante:
i6_71'" '377-1-47 CITY OF CUPERTINO-BUILDING DIVISION
• C4APPLICATION /PERMIT
/�f D� ,D NGE ECTR CA4 LUMBINGMECHAMGL CATEGORY
CONTROL I
ArdiLLect/Fsglrrcr. [Je Na
-QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE
LICENSED CONTRACTORS DECLARATION E
Ib'by affirmthat l amhmosed underprovldma of Clupler9(commess APPLiANCISRESIDENTIA D RRTION
ingwith Seetbn 70N)of DNiecto3ofthe Buslocis dl' oneCode,and my
lime.1.In full y/eff ect. 8 PANELS
Llcerunc�� a-L1, 7 pc,c.T /i.DDiotJ
Date ContractTun
or - 2011000A.MPS
ARC CTS D C RATION
N7 Lund hryslp0,ye y)edgubllc reoordi OVQt1W0 AMPS SQ.FT.FLOOR AREA S/9Q.Ff.
ww 4�1-C_J� L/t or SIGNS ELECIRI
k Z ssb 1
�<<< OWNER-BWILDER DECLARATION - SPEC)ALCIRCDIT/
71.. 6i 1herebyaflnuthat lam e.empt from the Contractors License law for the
op following reason.5eu1m 70315,Sualnnsra and ProfessioCode Anydry,or
TEMP.MEffIIi ORlA7
5 muntywhkh requlmapemdtmmrubuct,aler,lmpmve,demnlbh,orrepalr
��CC any structure prlorte,its baurue,abo requires the applicant for such permitto POWER DEVICES
eG
Bit,a signed statement Net he is limnacd pursuant to the provisions,of the
Contractor.Ltmrne Law(Chapter9(no.iming with SMB.7009)of DM-
VALUATION POOL ELECTRIC VALUATION
O;} tlaY
on3ofthe& neseand Pmdmbrm Code)orthat hebexempl thertGvmand
F3 6.Y the basis for the alleged exemptlom. Any violation of Section 70315 by any
eppllontfor.permit subjects thexpplicant to.&II parahy f.ot mort(ban OUTLEISSVITCFTFSHXTURFS
live hundred ddbrs(,LW. NEW R13lDFNIlA1,EITfIR FI.
❑1,u owner d the property,or my employes with wages as their safe STORIES TYPE CONSTRUCTION
mmpenaaHoo,wBldothe work,and the structure is not Intended or offered for
k 0 sale bee 70th,Businmand Prof.foru Code:The Contractors License law
r3$ donsnot apply to an owner of property who builds or lmpmvn thereon,and OCC-GROUP RRIS UMTS
E who don such work himseU¢thwgh his esus employees,provided that arch
Improveme os art unit Intended oroffered for sale.If,however,the Wilding¢ TOTAL:
Improvement bsodwkldn oneyearofcompletbRthe ownerbuilderwW hive
th,burden of pmdng that he did not build or improve for purpose of axle.). QTY, . PLUMBING PERMIT FEE
0 L as owner of the Property,am euvety hrnicontracting with BoomedETDDD ZONE APN
mousdon to mmmud the projM(Set,7044,Busing and Professions Code: PERMIT ISSUANCE
Tine Contractors Lkerie law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contnum for suth p(o)ects with a
ryL(ractor(ept in .
theCtractor's License SUMMARY
e w. BACK FLAW PROTECT.DEVICE
LJ I int exempt
p under Sm B&P C for this rtmn
• Ow.er Date DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N=
RECEIPTF
REC
WORIOMAN COMPENSATION DECLARATION FIX.NRF_S PER.TRAP SCHOOL TAX Y_ N
I hereby afflrm that I have a.¢rtfOmm of consent to self-Iwrc,m
¢b of Workers ComperyHonl rr�a ¢a¢rtUkd mpythertof Sec. RFGEIPI'/
]B00,Wr.f H)uoa'Ct. (/ GAS EA.SYSFEM-1 INC.4 OUTLETS PARK FIE Y_ N_
RECEOT 0
Pdky Y CAS EA.SYSTEM-0VER 4(EA)
Cum ray BUILDING DIVISION FEES
CertNed mpybhemby(umlthed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECR FEE
crtNed ropy b(fled w1N the dty InapMbn dfvWm.
CERTIFICATE OF FlEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SLWER-SANRARY STORM EA XIUrT DatC Remi [M
RhiseMbn need n(Le completed if the permN b f¢orc hundred dollar
0))or lm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit la hued,
1 shall not employ any person in any manner n as to become subject to the
Workers'Compensation Laws of CalBmnb. Date WATER SYSTEM/TREATING PAID '
Pp gQdr(, Date Rceei to
Z O NOTICE TO APPLICANT:ff,after mating t his CertNnte,of Exemption,you NEW RESIDENTIAL PLMB.
Amid become subject to the Worken'Compensation Inmisbru of the Labor TOTAL
Q N Code,you crust forthwith comply with such provbbro orthb permit"It be BU
ILDING FEE
W ] deemed remked.
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyalflrmtlut thercbammlructlon lendingagency forthe peAormry TOTAL: ELECTRIC FEE
7 Z an.of the work for which this,vormn b bued(See 3041,CIv.C.)
U O lender.Name CJ/>i PLUMBING FEE
LL H Lendee.Add� QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
InnlfythatIhaw mad this appli¢tba
nandumm
ethattheaboveinfowtl
O w
S Is mrred.l agree to comply withal city and evenly FSpAIU ondlnanm and state laws, PERMIT ISSUANCE 2
I'. } relating to Wilding mnatrutlion,fend hereby authorbe repreentalves ofthis ae�
[... N city to enter upon the above-mentbrcd property for impectbn purposus. ALTERORADDTOMIA W
Z (We)agree to Live,Indemnify..it keep harmless the City of Cuperman Date Reeei the
V
against liabilities,jedgmenb,costaandexpenneswhkh may manywayacvue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
against said City In mosequerce.f the granting(thb permit. AIRHANDLING4/N'IT(OVER10,000CF)v() CONSTRUCTION TAX
Signaunof AppO¢nt/Contraclor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllol or future Wilding acapart Mentor handle havard.s HEATING UNIT(TO IM,000 RTU)
m Date RLcei tis
material s defined by the Cupertino Municipal Cade,Chapter 9.17,and the
I leallh and Safety Code .255374)1 HEATING UNIT(OVER 10,000 BTI) TOTAL: altcfu
qYn
lllthe�pplbrd or tit¢bulldingoavpantuaeequipmentordevim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit bavrdous airmntamLunts xs deflned by the Bay Area Air I�r
Quality Management 1 gpn aft-COMP PIE'OR lfl(1,IXq BTU) P,
❑ Yes.. L o
Ihave mad the It...mous materials requirements under Chapter 6.95 of BORER-COMP(OVER 100,000 BTU)
the CalBomb Heahh&Safety Code,Senbru25505,TiS33and2 M.1 1990
uM"ard tifthe WOdmgdmrmc entiyhaveatenant,thatubmy NEW RESIDENTIAL ME(71. SQ.FT. O
responsibility trlmify the omvparu(the mqulmomw which mount be met -
p�orto esti to ofOmrparrty.
IJ City t�f (`!tr:�rtim►
nerve thorbred agent
Date ISSUED BY:�
'
TOTAL
OFFICE COPY