23564 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRWTNO.
B°dd�Addre: 23564
19705 Drake Dr .
rare .ma: oer.
252-4089 CITY OF CUPERTINO-BUILDING DIVISION
c"A"n ' G: Dc,N. APPLICATION I PERMIT
r-R- BUILDING-11B KALPLUMBINGME LAICAL CATEGORY CONTROL Y
AkAI ea nee. o
QTY ELECTRICPERMTT FEE BUILDING PERMIT INFO
Add.
PFRWTISUANCE ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I herebyefflrm that lam lkensed under provisions of Chapter 9(commenc APPLANCESRESIDENIIAL JOB DESCRIPTION
ingwith Section 7000)of Dlvision3ofthe Businnsand Pr.fnsionsCode,and
iensecll;asr$3�`k�`$' 346361 rnNFTs
Date C.,mestor ��-�►`-�Y"1"�+
ARCHITECTS DECLARATION 201-1000A.
{{{0yyy0 I undersand my plans shall be used e,public too, & OVER 1000 AMI'B SQ.47.FLOOR AREA S/SQ.FT.
Licensed Rderolonal SIGNSELECTRICAL E D I fi�
< OWNER-BUILDER DECLARATIONUI
SPECIALCIRCT/MLSC
7 a Iherebyafflrmthat l.mexempt(romthe Cnnractorb Llcenselaw le the
f ilowteg reason.(Section 7MI5,Basins and Pm(embns Cade:Any city or TENI'.METER OR POLE INST. T E
K�Ly muntywhkh rcquUnapermBtomvtruR,titer,4npmve,drmoWh,ornplr R
S �� anyMru¢,reprlortolafseuaricgabo,equkmtheappll¢nt(o such pemdt to POWER DEVICES
t5 o O O4 a signed statement that he b licensed pursuant to the provisions d the
ESQ Contrstlors Llcerse Law(Chapter 9(co,nmentlng with Section 7000)of Divi- DATE
do.3ofthe Bu An.and Profeslons Code)or that he is exempt tberefroms nd SWINCMING POOL ELECTRIC ATION
y.' the bash for the alkeged exemption. Any violation dSGlon 7/18[5 by any
�p3 appecanttor.perinit o,bjectslhesppWanttoatlWl penskydnn nnrethan OUII%ISSWITCHIS-FIXTURES
ppp Ove hundredddls,shepr. NEW RESIDENTIAL E[ECIR SQ.F7 SNAILS TYPE CONSTRUCTION
❑I,as.worn l theproperty,or,rayrmpbyen whhwages n thelesok
roleCn 04kwllldothe workand theelrutlurebnot Wended or dlered for
$�n s4 t5ee 7061,Busiras and]idesbns Code:Tin Gowratlofs LI¢nse Law
S$ don norapply to an owner d property who bunds or improves thereon,and OCC
.GROUP RES I1NIT5
who doessuchworkMmseBothrough Mwan
sonemploy ,provided thatsuch
Impnovemenb art not Intended oroffeend f¢sale.If,however,thebulldleg n TOTAL:
Impmvement bdd wWdn.neyearofcompletlon,the ownenbuiWerwil terve
t ,den of proving that M did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
Lj L e,owner of the property,am exclusively contracting with lid FLOOD exclusivelycontractingeensA]'N
mntractonto m,avuct the project(Sec7044,Bu ines.nd lhofeslons Code: PFRhTCT ISSUANCE
The Contractor's Lkc,ne Law dm nor apply to an owner of property who ALTER-DRAIN 4 VEM-WATER ffA)
builds or Improv constructsthneon,and who cofor such ptojem with a
Ice,reed pursuant to the Contactor.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec B h P C for this reason
•
QLITSIDLFEES
DRAPNSFLOOKBODEAREA,COND. SANITARY Y N—
Owner Due ItFLdPI'Y
WORKMANMEN
COMPENSATION DECLARATION
01 hent/affirm that I have a certitreec d coesnt to opy two,ors FDCfUPXS PER TRAP SO100L TAX Y_ N—
RECEa't,s
¢oblnsuran¢ate of Worken'Comperuatim l ¢ u
aatdkd copy thereof(Sec. GAS W
FA.SYS EM.1 G4OUn EIS
3800,PofikyYb G) 1 01 2144 PARK FEE YRhcF3PT4—
Cpm eY— GAS EA.SYSTEMIOVER 4(EA) BUILDING OI VISION FEES
Ce,tiliedon -by hunWhed.
IT
enured copy Is filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIF'ICATEOFID(EMI'TION FROMWORKERS GREASE TRAP PAID
COMPENSATION INSURANCE
SEWER-SANITARY COMPENSATION
EA,XxIF-r Date Rett{ t#
(TMs section need rad be completed I the permit bore hundred dolsn
($10worles.) EE WATER FFFATER W/VEM/E[.EL7'R ENERGYFY N
1 certify that In the peri.man¢tithe work for which this pemd
t b issued, —
I shall not employ soy person in any..net n a to beroma vbfcct to t W WATER SYSIiM/TREATING
Worlvm Compensation Laws of GWarnia. Date PAID
O Z Applicant NEW RF9DFNIFAI,[LMB. SQFI. Date Reoei t#
Z O NOTICE TO APPLICANT.I,etur making thio Certificate of Exemptlon,you
should become subject to the Workers'Compensation pnvvbbns o/the Labor TOTAL:
CC N Code,you must fonhwhh comply with such peuvlslonsorlhbpermX atWl be
LU j deemed re olu d. BUILDING FEE
LU
CONSTRUCTION LENDING AGENCY SEI IC FEE
I herebysfflrmthatthereba construction lending agency for the perforin roTAI_ ELECTRIC FEE
7 Z erns o/the work!car which thio perMt biomed bee 30ffl,CN.C.)
U O Lender's Name PLUMBING FEE
LL ~ Landel.Add,es QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -
U Icenlfythatlhawmre thbappliotlonandstatethatlhe.bove lnfonvtlon
O W loco,ct.lagreet.complywuhallcilyandrounty.dman¢,andeatelawe PERMIT ISSUANCE �' FEES PAID:
} a rebting to building construction,am hereby authorise represnteuves dthb
F N city to mar upon the atsovrmantlorad property for inspection purposes. ALTERORADDTOMH.
z (We)agree W save,Indemnity an d keep harones the City of Cupenmo Date Reeci t#
U a,ecatl bWtb' gmanb," and expenses which may In any wayacaue AfR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
agalou dC sa(ue the gr.ding d this pe
onftA -L_ AIR FLAN UNG UNIT(OVER 10,000CF1.1) CONSTRUCTION TAX
e of Ap /Contract¢ n EXFIAUST HOOD(W/Dues CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllonWfuture building ocovpact no,e or hand le h.rd.us HEATING UNIT(TO I W,000 JIM Date Rec '
material as defined by the Cu pertleo Municipal Code,Chapter 9.12 and the
1 leach and Safety Cale Section 255320)7 1[EATING UNIT(OVER 100,000 BTU) TOT
E— Yea N.
Wtheapplicant.r wmbufldingosupantusoequipmauode lies; VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whkb endt havrdous air mrammeal.s deflned by the Bay Area Nr
Qualuy Management Dbtrktr BOILER-COMP PFI'OR l00XW RM
Ya ❑❑� PARD
Wvc read the hazallous materlab,aqulrements underCW par 095 a( BOILER 100,0008TU)
the
understand
Health bSafety Code,Sectlonsntly have
and25534.I
undenebtRytt if tilythldingdonrwtcvrreniiremon ate cIE tlutlt boy NEW RESIDENTIAL MEIN. SQfT
nnp.nsronuyto nctnythe.avpaatccupa cy.brmenn which nv,etM rrM OCT 29 1c^�
prior to Lreuance daCenifkate of Otapanry. (' � �r
Owneroawhcrivad agent Date ' G '/ t
SSUED BY:
OFFICE COPY