19913 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proect Identification 7 PERMIT NO.
Building Address: D19913 ,
aces: Phone:
CITY OF CUPERTINO-BUILDING DIVISION
Lie.N°: APPLICATION if PERMIT
BUILDING-ELECTRICAL.PLUMBING-MECHAMCAL CATEGORY 11CONTROLO
ArcFlt d/Engineer. Llc No:
QTY ELECI'RICPERMIT FEE. BUILDING PERMIT INFO
Add.:
PERMIT ISSUANCE �'I ❑ ❑ ❑
LICENSED ONTR under provisions of
- I�
Thereby ion70thetl iv Bcm3 oftheerinessaonsof ChionsC(common APPLIANCECRESIDENITAL JOB DESCRITMON
Ing rend Sed1on7000)of INvielon3 ofthe Business and Professions Code,and my
licenae Is In f ren end M(eR. PANELS /q! s
Llate LIe.ractor b.s-TG �.9a?112 `.'("Irk P'YI AI K ate Contractor
ARCHITECPSOECLARATION MI"IOW AM
rc02 7understand my Ohm ehaB be used as public records OVER IOW AMPS SQ.Fr.FLOOR AR S/SQ.FT.
O
U Licensed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION
rn]a SPECIALCIRCUIT/MISC
Zt, Thereby a(Brm lOWNE " mptfromthe Contmdor's License Lawfothe
!allowing reason.(Section 7031.5,Business and Pmfesslons Code:Any city or
O TEMP.METER ORPOLE INST.
�M a yatm m mgrmitspermit
e,constralsore ct,alter,uirestheapliant fmoWh,er repair
any stmdure statement
Its that
he i,also sed pursuant t the provisionessuch ofpermit e ppyyEg DEVICES
(lie o alter',statement that he t licensed pursuant it the provisions of the
3u. Con3oftheLi es Lew(Clupter Codmenci.theis5ed1on7W0)o/Dlvl-
H�OS el.n3o(the Buelneesend Pto(embre Code)orthat hebemmpttherelromand 5V'MMING POOL ELECTRIC VALUATION of
6 the basis for the alleged exemption. Any violation of Stolon 70315 by any OU METSSWITCH6S.FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not acre than
flue urdred delta.($500). 'vv
NEW RESIDENTIAL ELECTR
I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE NSTRUCTION
compensation,wlll dothe work,and Mestruchom is not intended or offered for
O sale(See 7040 Bualness and Professions Code:The Contractors License Law
3$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who does suchwork himself or through his own employees,provided that such
Improvements are not intended oroffered forsale.IL howevegthebuili ing or TOTAL:
Improvement bold withinoneyearo(compldlogthe owner-bu0derwBlhave
I rdeaofproving that he did me build orlmprove for purposeofsale.). QTy. PLUMBING PERMIT FEE FLOOD TONE APN
L act owner of the property,am exclusively contracting with licensed PERMIT155UANCE
cont.&..to conalmd the project(Sec.7014 Business and Profemlom Code:
The Contcadoes License law does not apply to an owner of property who ALTER-DRAIN AVENT-WATER(EA)
bulids or Improves therms,and who contracts for such projects with a
otal[ador(s)hrensed pursuant to the Contractor's License Law. RACY FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this masonOUTSIDE FE
Owner DRAINS.FLOOR ROOF,AREA,CON). SANITARY Y N
Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y_ N_
❑I hereby a!(Iers that I have• I nuounc of consent m self therso,ore RscEB?M
certificate ofWorkem'Compenaatlonlvuranaoracertifled copythenwf(Sec. GAS F.A.SYSTEM-1 INC4 OUTLET
3800,Isis C. PARK FIE Y_ N_
P.liryM GAS EA.SYSTEM-OVER 4 MAI RECEU'TM
Com B UILDING DIVISION FE ES
Cert ed copy b heed with the city GREASE/INDU5IRL WASTE INTERCEPTOR PLANCHECK FEE
❑cemBea copy b ales with the dry Irepr'dlon alwbmn.
CERTIFICATEOFBXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE -
(fhbsectlon need eat be.ompl TI Bthepermit bCaracas hunre
dd dollars SEWER-SANITARY-STORM EA.MEET. Date Remlt#
(S103).rless.) 14ATER ITER W/VENT./ELECTR ENERGYFEE Y N
I comlythat In the performanceo/the work for which this permit is Issued,
I shall not employ any pemon In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. QFf. Date ReCCI IN
Z O NOTICETO APPLICANT:If, ki
after mang this CenRlcate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such pow6l..mild.permltshall be B t�
W > deemed revoked. FEE'
0. G CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
I hercbya(0ren that there b a construction lending agency for the perform ELECTRIC FEE
Z ance ofthe work for which this permit b headed(Sec.3097,CIV.C.) TOTAL:
V O Lender's Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
OW Icertifythat(have readthbapplicationand Yatethalthe above Information
1 bconed.Iagree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building mwtrudion,and hereby authorize representatives ofthls
F_ Z city to enter upon the abovementioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Recei IN
— (We)agree to save,Indemnify an d kesp harmless the City of Cu pertlno AIR HA UNIT aga Inst liabilities,ptdgments,mets and expenses which may In any way accrue SUBTOTAL:
ata ,City In consequence.(th ming this permit. -
�� J AIR HANDLING UNIT(OVER I QOOO CFM) CONSTRUCTION TAX
Sig reof Applicant/Cont for a a/Dade��V EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAL4R US MATERIALS DISCLOSURE
Will the applicant or(u arc building occupant store or handle hazardous HEATING UNIT(TO 1W,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date RQCCI tb
Ifealth and Safety Cede,Sed 32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: a
❑ Yes '
Will the applicant or building occupant use equiEurnamt Area
devices VEN"DLATION PAN(SINGLE RESID) ISSUANCE DATE
which eMa agement air contaminants as de0ned by the Bay Area Alr oq!!
•
Quality Management Dbtnd7 BOILER-COMP(31(PDR IW,OW BTU) P 6"a!D
I Yea
haw.read the haze out matee,Sections255enbunder Chapter. 1 of BOILER-COMP(OVFR 100,000 BTU) r
the CaliforniatandtHealthA building
Codsnetco s75505ave a tand755M. I
re, cost ndthatnlithe notify
the occupant not erequi oonts which
that it boy NEW RESIDENTIAL MECH. SQ.Ff.
reser o issEtym ndltythe occupant dthercqulrcmema which must be met
p r oLssuanreo(a Ccrt to cop nry. �
�' ) cf GeT prtin
•
AcrocaullhocIrcclaf D e
TOTAL, ISSUED BY:
OFFICE COPY