19756 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT'PEN ONLY
Building Pm4ect ldentlflatloo PFRh9T NO.
Build Ing Add ren:
19756
l0�3�TA tJT�}U
r. ,r--. one: ,
T GAF)Lk CITY OF CUPERTINO-BUILDING DIVISION
• Con .N Lk.No: APPLICATION / PERMIT
I�/�/�I ��f-C�+f- G 'C{f7- (o '4-.13BUILDING-ELECTRICALPLUMBINC-MECHANIGV. CATEGORY CONTROL♦
ArchX°y�/Engineer. Ile Na
1 f� .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE �2,� ❑ � O LlLICENSED CONTRACTOR'S DECLARATION
I hereby aBbm that l am licensed under provlebnaof Chapter9(mmmen APPLIANCMRESIDENITAL )00 DESCRIPTION
Ingwith Section700D)of Dh bdm3ofthe Susiressand ProfeaVonsCode,and my
Licer b In Ml(ore and dfeR PANELS �r
Date Chs Cont 1�
Dae Contractor '
ARCHITECTS DECLARATION 2131-10DOAMPS _j A_%
00 Z I understand my phN shall he used as public reon ds. OVER IODO AMPS SQ.F7.FLOOR AREA $/9Q.FT.
w
r Z u Lkm
xed PmfealONi SIGNS ELMRICAL
<� OWNER-BUILDER DECLARATION SPECIALULT/hvp r\
Iherebya(firtn that l ameaemptfmmthe Comranor'•Lk<Ne Law for the
qqqq following reason.(Sedion 70115mnd
,SualnaProfenloN Code.Any city or
Fg owhich n
nty which ns
aa permit tomtrom alter,Improw,demolish,ormpar TEMP.M
5 anyarn =mprlortolbl ampaLs mrequimtheappbantfarsuchpendtto POWER DEVI
W 5 file a signed statement than he b licensed pursuant to the provbbns of the
Gq Comnctoh Lkevelaw(Clupttt9(mmnencingMthSeabn70(ID)ofDlvl-
FE, .don 3 of the Business and Professions Code)or than he b exempt therefrom and SWIMMING L C VALUATION
<.•�.a1 the basis for the alleged eaemptbn. Any WdNbn of Seabn 70715 by any
appilant for a permit subjects the appLam to a cisal penalty a(nd mom than
p five hundred dollars($500). NElV REED EIFLIR
[d.•gym F]1,as owner of the property,or my employee with wages.,their sole S 'FT' STORIES TYPE CONSTRUCTION
mmpersation,will clothe work and thestmciure is not intended or offend for
S 0 ole(Sc.70K Business and Aofcmbro Code:The Contractors Uo:tme IAw
don not apply to an owner of property who builds or Improves thereon,and
r-$^ whodoevurh work himtelforthrwgh Maownemployeea,prwided that seer OCC.GROUP RES UNITS
imp red are not Intended oroffereci for le.It however,the building or TOTAL
Imp ntbadd with
inoneyearofcompldbn,lMowner-Wllderw0l have
rdrn nits ngthrtkdd riot Wild ar lmprova nor purpose Oracle.). QTY. PLUMBING PERMIT FEE
1,.,owner of the property,am eacbsivety mntracdng with Ikm.ed FOOD ZONE APN
PERMIT ISSUANCE
mntraeton to mrstroa the projed(Sm 7034,Busman and Professions Cade
The Contndori Lbanse Law dm not apply to an owner of property who ALTER-DRAIN La VENT (FA)
bull"or Improve thereon,and who contracts for such project•with . FEE SUMMARY .
gLV+aar(p)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B 6 P C for thio mason OUTSTDFHES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Own<r Dae RFLDPI'Y
WORKMAN COMPENSATION DECLARATION F)CTURFS PER TRAP SCHOOL.TAX Y N
1 hereby affirm that I have•certificate of mssem to self-Inwn,a a RECETT Y
aertifioteofWorkee'COmperuatlon lnsunna ora certlfled ropy thr.fGo, GAS F.A.SYSTEM-1 WCIOUTLETS PARKFEE Y N
I'dlryl �Ccycy_7r l 1 RECEEFTY
Co�anv n GAS E1'gYSTPM-OVERI(FA) BUILDING DIVISION FEES
d♦lied mpybheraby furnished. GRFASEANDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ied mpy Is f0ed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATION INSURANCE SEW02-SANITARY-SIDRM FA xI®•l'. Date Repel t#
(This.ectbm
n need not M mploted B the pem It b r
for one hundred dollars
(slcmaelea.) wATERFFATFR w/vFxr/FJ FITR ENERGY FEE Y N
Imrtl/yt tintheperfor mOftheworkforwMch Indspem tlabated,
L shall not employ any person b any manner no as to become,subje t to the WATER SYSTEM/TREATING
Worken'Compcna.tbn Lova o/Gllfomh.Dat< PAID
PP gQpy, Date Remi ted
Z 0 NOTICE TO APPLICANT:If,ager nu king this Certificate of Exemption,you NEW RESIDENTIAL PLMB.
should bemme.ubje&m the worker;Campematbn provisions of the Labor - TOTAL:
~ N Code,ywoa•tforthw h¢ plywthsuchprovb morthbpem hour
W > deemea revoked.. BUILDING
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby.fOrmthat therebamnstmctionkMingagrncy brtM pedorm ELECTRIC FEE 7
7 Z enre of the workfor which this permit b issued(Sec 309/,CL,C) TOTAL
(� O Lender's Name PLUMBING FEE
LL F Lender'.Addis, QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW ImrtlfythalhavenadthbappUatbnand•tatethatheabovelnforrrwlm
It. lsormct.lagree to comply wtlh sBchyard musty ontinanmand eiatelasva PERMIT ISSUANCE FEES PAID:
relating tm W ilding construction,and lu n by.ulhorire representatwe of this
F N sty to enterupon the abuse-nenlbNd Property for WpMbn purpose. ALTTRORADDTOMFLH.
Z (We)agree 1.saw,Indem afy in d keep harmleae the City of Cupeniro Date Recel t#
V against liabWtln,{sdgmeNa,mansard expense whkh may In any.y..e AIR HANDLING UNIT(TO 10,000 CFh0 SUBTOTAL:-
against
UBTOTAL.against said City In conaryumm of the granting d this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Apphant/Contractor Date EXT-RUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building omupant store or haMk h..,dous HEATING UNIT(TO 100,000 RTU) Dale Revel t#
material as defined by the CCCCCCyyyyyypt rtlm Municipal Code,Chapter 9.17,and the
Health end Safety Code, 2553I(a)7 HEATING UNIT(OVER I MODO BTU) TOTAL: �. t
n❑
Yes, No C��p
WOb the applam or future build Ing oocupant use equliment m devkcs VENTILATION FAN(SINGLE RESID) .ISSUANCED TE
whbh,mlt haranlous air mntamW rate s defired by tM Bay Area Air
• Quality Managamant Dbt 7 BOIIFR-COMPOHPOR100,000BTU) EM
Ye NO
rh ven.dthehan Ousmaerlabrequlremenbunder Chapter&95of BOIFR-CONP(OVER 100,000 BTU) 'y TTo
the GBfornh Heath k Safety Code,SenbN 25505,75533 and 75534.1 �. �, j N U J
underwndthat lftM Wilding does riot mnently M1avcatenanL that Xis my N'EWRESIDFNTIALMECH. SQFT.
mpns30Xymmroafythe.p�arn othe req nrnent•whch moatbemut
PAaCnt WaY - W�y7r"f,f . i
�v
YZ/ZG/F-o
Ter oaIlhoeredagent Date TOTAL ISSUED BY:11� '
OFFICE COPY