19768 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B
uilding Prol Identification PEtMITNO.
IIIIng � � E 1,9768
- oro: r
j 23 CITY OF CUPERTINO-BUILDING DIVISION 3 _
_ k�17lL�IfG Z .NP APPLICATION /PERMIT CATEGORY -3 O CONTROL IA(� BUILDINGELBCTWCALPLUMBING-MFLIIANICAL
ArcM1LLect/Fsglneer.-1 Lk.No
jsi _ .^ Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address( 2 (-i' LJq,r 7^ PFRMITISSUANCE ❑ 1:1 ElLICE SEDCO. ACTOIPSDECLARATION
Iherebyaffirmthatlamlken uMe pr Wwsol Chapter9(convnas APPLIANCESRESB)ENTIAL JOB DISRITION
Ingwith Section 70M)o(Div sim3athe BunrcsandPmfeWmsCode,and my
liberee h N full=and fffect. ` /_ O PANES
_12�Ccmurxacur I,^ UP TO 2DOAMS
ARCHITECT'S DECLARATION 201.1000AMPS
OZ I understand my plana shall be used n public records OVER 10)0 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Lkeved Prolembeal SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CSRCIIR/h9SC
I.., / IherebyaRirm that l am exempt from the Coaractori License Law f¢the
z Q following reason.Section 7m 15,Bushes ami Professions Code:Any city or
027
/,i. TEMP.METER OR POU INST.
E cwntywhkh requbesa permit tomrutmct,atter,Improver derrrLh,or mixer
anynna=mpdortottahsuarcgalsorequbnlheappb¢nt(ma &pemdtto INYWER DEVICES
O O flit•signed natement that he k licensed pursuant m the pmvhlom of the
Contractor.Llceroe Law(Chapter 9(mmmencing with Section 7000)of DWI. SWIMMING POOL ELECTRIC
3� abn3ofthe BuelnmsandPdesbruCode)onhrt hake lhertlromaM VALUATION
< the basis for the alleged exemption. Any violation of Srtmptnb 70715 by any
appllcant for a permit subd
jects the applicant to a ell penaltymore of not mathan OTTILE7SSWITCHESFIXTIIRFS
flee hundred dollars MW.
$ y n I,an ownm of the property,or my employees with wages as their sok NEWRESIDENTIAL ELEC A SQFT. STOWS YPE CONSTRUCTION
mmperwtion,will dotibe work and thenmet re h flat Wended or offered for
r) sale(sec 7014,Bushes and Prefes.bm Code:The Contract.e.License Law
(j5S don net apply to an owner of property who builds or Improves thereon,andOCC.GROUP RES.UNITS
33 whodoereurh work hlmselforthrwgh hlsownemplcyen,provided thalsuch
Improvemew are rat Intmded oralercdfor••I. If havever,thabulNL inger TOTAL, f/�/
Improvemer4hwld wLLM1lnorcynracompletlon,theamer4sullderwBl have y
t)LtVdeo of pmving that he did na wild or bnproee for purpose of.,k.L QTY, PLUMBING PERMIT FGE
LJ I,as owner of the pmperty,am exdulenly mntracung with licensedEfJDD ZDNE AI'N
contracian to construct the pmjeet(Sm 7014,Businesi and Prulesbru Code: PERMIT ISSUANCE
Tie Cordnctor's Llan Law doe nes apply to an owner of property who
WWa or imp. there , and who remoras for such p,jeN with a ALTER-DRAIN&VENT-WATER ffA)
c�facmrW Licensed pursuant to the Cmtncio.Lkene,Law. FEE SUMMARY
LJ I am exempt under Sec B &P C for thin rceon BACK FLOW PROTLCT.DEVICE
Owner Dare DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
RKE9 e
WORK N MACOMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
hereby affirm the I haw•¢Mfl¢te of consent to sell-Inuit,or a RFAELPf.
38m,Lab 1ab CJ Worker Comperisatlorilruunn¢oa¢rtifled ropythrrta((Sec. GAS EA.SYSTEM-1 rNC.40UTLES PARKFFE Y_ N Polley RECEIPT/
If CAS.F.A.SYSTEM-OVER 4(EA)
Com y BUILDING DIVISION FEES
I�C�rtBlea copy Is henq bole city GREASE/INDU5 RL WASTE NTERcmTOR PLANCHECK FEE
Conif ed copy h flied with the city inspection div W m.
CERTIFICATE OF E(EMPL'ION FROM WORKERS GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.ma;1. Date Recei HI
(fhh need nes Mcomplcicd lithe permit h(or ora M1undred dollars
(Slm)¢1®.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
1certify that in the ormen¢ufthe work forwhich thisperrNt h hued,
I sbe]nes employ any N any manner so u to become subject to the WATER SYSIFAI/T3tFATING
Wurken'Compensation Laws Ilfomla.Date PAID
O = Appll¢nt NEWR6gDFN'DALPIMB. SQlT.. Date Retei tit
Z O NOTICE TO APPLICANT:If,after, CeMfiuteofFummvpttbm,you
P N shwldbemnesubjen iothe Worker compo ion provhbmofthel-bor TOTAL
Code,yourr.rstfothwithmrnplywithsurhproeM roorthhpermlfeallbe
1U dm rewked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. Thereby thatthen ha mrutmctlonkMIng agerry for the perform ELECTRICFEE
M Z an oohs soon whkh this permit h issued(See](19'/,Civ.C) TOTAL:
00 L<Mer.Nams PLUMBING FEE
Lender.Ad;d QrY. MECHANICAL PERMIT FE•E
O W Icenuythatlhaec read this .l�tkm and nate that the above Information MECHANICAL FEE _ OD
fl h mmct.]agree to comply with. nes countyomllnanmand nate laws PEZMUISSUANCE VD FEES PAI D:
>. N rdatingtowlldingmnatructim.rd he uthorlx raenterw+nflhh UO
cit toe ntheawve-mendoned a ion ALTER OR ADD 7O MECH.
~ ? y )ogee o sees,Indemnify an d keoep h City.f Cap pulp..
Date Retei tit
V ag WbW dgmenls,mesa erysen kyr Lln an ywa AIRHANDL1NCUNTTUOI0,000CFM) SUBTOTAL:
a I id la a Atli •pen �3d AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
/ � CONS RUgT7 ON TARPA D:
i 5 o(AppB¢nt/Contndw Date EXHAUST HOOD(W/DCCT `(IJ-J-�-a-P=-L
HAZARDOUS MATERIALS DISCLOSURE
Bl the applicant bu0dln66 aavpant rtore orhaMkM1anraaaf HEATING UNITCIA 1m,000 BTU) Date RCCeI to
mule defined by the Cupertlrw Municipal Cade,Chapter 9.lZ and the
1 11%a sty Cade Section 7553]W7 HEATING UNIT(OVER im,Om BTU) TOTAL:
❑
Y. No yIN'HLA770N FAN(SINGLE RESIU)
Will the applies Nm wilding occupant ryulpmentodevko IS$L�yDATE
whfcheM[hanrdoua ab mwnn as deBrcd by
Bay Arta Ab ��'U6�
QuAitymeagerrcMD�is 7 BOMER-COMPOhO'OR1m,000BTU)
Yes ���44((IINNcto a/' T
r-1 Yen
cusmateriale menbunder Chapter 695of BOILERCOMP(OVER 1m,0WBT(A h'/ R 3 01990
�IM California Health&Sa lety Code,Sectbrm 75533 and]5534.1
eMmoMthatlfthewudingdonwtmmntlyh atenanLthatitlamy NEW RESIDFNIIALMEIN. SQFI'.
rnpm [bULtytonalfythe.N.tofthertquirtments bhrrustbemet City of /kupe�no
prier lu tsua ma a a ycrU occupa Om>pancy. V151 Ia
Avner or authorised agent Date TOTAL ISSUED BY:
OFFICE COPY