19615 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address 19615
105122 D( AN L00
sone TameCO v 914 Phn A A
CITY OF CUPERT[NO-DUILDING DIVISION
< N APPLICATION I PERMIT q
D
BCATEGORY CO NtrNmUDING-ELECTRICAIPLUMBINGMECIIANICAL
Arch
�
LLsQTY ELECTRICPERMIT FEE BU ING PERMIT INFO
Ad1es5 Or_N4ek) T•
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Hearted under provision,ofCh.pm,9(mrruran APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Sedion7000)of Division3ofthe Buslnemand ProfesslonsCode,and my
license lain full mans, effect `�y PANELS T a l�ev /a/�J/ W1
Date CIN j �Llr.Y b"1 'a—rV 7 G/'�' Y�L'/r I
Date Contractor
ARCHITECTS DECLARATION 101-IOWAMPS
07 I understand myplansslatUbeused as publlerecmds. OVER1000AMPS - SQ.Fr.FLOOR AREA S/SQ.Fr.
❑❑O Llarued Professional SIGNS ELECTRICAL
(L
6 uuN OWNER-BUILDER DECLARATION $PECIALCIRCUIT/MISC
ZE, a Iherebyaffirmthat l am exempt from the Contractor's License law for the
M following reason.(Section 7031.5,Business and Professions Code:Any city or h I 000,O Q a
OTEMP.METER OR POLE I cL
�� cmntywhichrequre apermlttomrmtmd,alkpimpmve,de=l6korrepalr
.� anystmmum prkrto Its beuance,also requlreatheappHant forsuch permit to POWER DEVICES
filea signed stem
taent that he 6 licensed puuant to the provisions of the
OwC, IL
Contractors License Law(Chapter 9(mmmencing with Section 7000)of Divi. SWAIMI IA]OL
TL
ekn3.flh.BusInes...dPd.im®Code).,thathe6exemptthemfromand VALUATION
S° the basis for the alleged exemption. Any violation of Section 70115 by any ���� -•v
psppUcant fora permit subjects the applicant to a civil penalty of not rnorethan OUTLE TC Q s
five hundred dol6n(950M. NEWWSIDWALELTSQ.Ff. 5IOR1F5 TYPE CONSTRUCTION'
..�n ❑I,as owner of the property,or my employees with wages as their sok
C mmperuation,will dothe work,and the structure 6 not intended or offered for
$' O vie(Sec 70K Bus"•o•and Professions Code:The Contractors License Law
jr does not apply loan owner of property who build.or improves thereon,andOCGGROIII' RES.UNITS
whodoessurhworkhlmseff orthrough hisownemployees,providecithat soh
improvements are not intended proffered forssle.If,however,thebuilding or TOTAL:
Improvement bsoldwithin oneycarofcomplatlon,the caner-bu Oderwlllhave
tlitTLdenof provingthat he did ndbulld or Improve for purpose o(sakJ. Q PLUMB IN PERMIT FCE
LJ FLOOD ZONE APN
co. L as owner of the property,am exclusively Business
ess anding with Ilansd IT ISSUANCE
The Co onto mwWd the project(Sec.apply
Business and I'rdassloru Cade. -
Wil Contractor's I Prs Limine Lw does rad apply to, f owner of property who
Wilds or Imprwn thereon, and who mntrem for each p(opcta with a LTFR-DRAW kVENT-WATER(EN
Tacom,.)licensed pursuant to the Communal'.Lt.. FEE SUMMARY
jI am exempt under Sec. B h P C for this reason 'BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,A CO SANITARY Y N
® Owner Date RECEIPT Y
WORKMAN COMPENSATIONfc.DECLARATION FIX'NRFS-PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have o certificate of consent to seff-houre,or RECEIPT Y
38M,L.bC.�dlituteofWorkers Compewtloninsuranmcacertifled copythermf(Sec. GAS.EA.SYSTEM-IWC.40 PARK FEE Y_ N
3X00,lab C.)
I'oliry M RECEIPT M
GAS FA,SYSTEM-OVER (FA
Com any BUILDING DIVISION FEES
Lffertlfied copy is hereby furnished. GREASE/INDUSIRLW FJ' R PLANCHECK FEE
"
IizoKi(led copy 6filed with the city Inspection division. / �(
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID 'L," y15•X,40 6
COMPENSATION INSURANCE ..11 e•��
(Thlasedlonnead ndbccompleted lithe permit 6forone hundreddollars SEWER-SANITARY-STORM EA. Date . Reeei t# 419Z
($100)orlaxx) WATER HEATER W/VENT/FlFCTR ENERGY FEE Y N
I mnRythat in the performer ceof the work forwhich this permit is issued,
I shall not employ any person In any manner an as to become subject to the
Workers ws Compensation Laof California.aATER SYSTEM/TREATING.Date PAIDdrl-flo 016 A_)406
Z Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
Z O NOTICE co esubjnttothe, ore m'kinglh6Certlflple l molt eL&o
should become forth to the plywit'Comprovisio provhis peofthe Lab or TOTAL:
� ; Cade,you=at forthwith comply with each prov6loru.,this permitshall be BUI I G i 153q.o
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il 1hambyaffirm that there 6 a constmdion lending agency for the perform- TOTAL: ELECTRIC FEE
� Z ancooftheworkf whichth pe Pit 66 ed c.3097, vC
UO an Name LF PLUMBING FCC
LL I— Iemder.Address- J QTY MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtltythatlhaverea t pp 1 nam stater attheabmelnfomstion
(L ismrred.Iagreeto comply with all city and countyordtnanms.ad elate laws PERMIT ISSUANCE FEES PAID:
>. N relating tobullding mmtrudion,and hereby authorlu representatives ofthis -
I— city to enter upon the above-mentioned property for inspection purposes. I ALM OR ADD TO MFCH.
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
O agaust liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalru i ity onsequena f2Ee Ing of this permit./ /
/ GD AIR HANDWNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
2
Signakreof Appllant/Contrador Date ExHAus r HooD(W/Duc13 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or hatme building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Reeef t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Ilentil,.and Safety Cd dlon 75533(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will thea pplinnt or Nm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSj#[>.Jra6.DATC
which emit haardouaalrcontaminants.,defined by the Bay Area Air fH�111111r/a Quality Management D_�s�l t7 I)OILER-COMP ptm OR 100,0M BTU)
4 Yes IXj No . 1
havenia ealth aT777dddafty Cod,Sections
2505, under Chapkr.1 of BOILER-COMP(OVER 100,fM10 BTU) MAY U't,
theerstanCalffon la Health k building
Cods Seccura75505,ve a tenant,
that ] t
understand that if ttlyhe the occupant note mquirean athich that b is my NEW RESIDENTIAL MECH. SQ.FI
naibUllytm nday the occupant of O ftherequlremenls which must be met City of Clinrrtinp
^ Lssuanno i to of Occvpanry. � -
�, (M�
mer or authorlud agent Date -TOTAL: ISSUEDBY: h
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OFFICE COPY