19702 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building I'Wetl Identification r PERMIT NO.
Building Address:
�aZ{:z �osIa cl► LOT .9 19702
nen ams: �j - Phone: � � p �-
SEp { ZSS•2Q8 CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT [
y '• "N'\�S L I •�IS'� Saz BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORYCO N
Arohb �pn C' Lk.No: _. ._ .
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QTY ELECTRIC PERMIT 'FEE. BUILDING PERMIT INFO
Address: / Q MV 2—
PE4MITISSUANCE,
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrm that l am licensed under provisions of Cha per 9(mrsome APPLIANCES-RESIDENTIAL, JOB I PSC ON
ingwith Section 7000)of Division 3 ofthe Business and Prof tudonsCode,and my
-
licentaislaft:11jarocandeffect. PANES'
Llcenlc Class Y Contra
Z ' 1/
Date CCentra orJ
ARCHITE S ECLARATION 201-1000 AMPS
Z I understand my plane shall be sed aspublicrecords. OVER 1000 AMPS - SQ.Fr.FLOOR AREA $/SQ.FT.
F Llmnsed Pretreat.. ELECTRIGHL. ^ ab'� - {v
U
6 Fg HOWNER-BUILDER DECLARATION SPIALCIRCUIT/M
pQ., I hereby afBrmthat l am exempt fromthe Contractors License law for the , Bass
F 2 r a following reason,(Section 7031.5,Business and Professions Code:Any city or METE4DR It; INOV
- 4 -Gdk4GL,
ti ;
countywhtre requires st issuance,aluore uires thea pmvent fors cher to / -
g any atsi ned prior tentsthat
he6licensed pursuant t the provisions
uch ofpermit e
FJ I (Be a signed kens statement that he Is r 9(coma encing l it the pro 7000) of the -
312 sion on 3 oft hes urines Lew(Cha erg Code)
with xemptthere of and VALUATION
"
rn M B SWIMMING IXJOL ELECTRIC
H�Oa slabx,Lhe Business ProfesslmiC Any
Isexemptt031,5 by any -
6.•..11 the liosis for the alleged esctxthea Any violation penny on net core any OUTLETSSWITCHMFLCFURES
applicant fora permit mbjectsthe applicant to a civil penalty.(not more 13en
flvehunwn
dred dolWn($500). NEWRESIDENHALELECTR SQ.FI'. •� STORIES TYPECONSTRUCTION
�n ❑I,as oer.(the property,or my employees with wages as their sok
e compensation,wllldothe work and lhestru"ure lanai intended or offered for
5 O rile(Sec.7064,Business and Peefesslaw Code:The Cmumciors Llmree IA.
r $$ does not apply to an owner of property who builds or improve thereat,and OCC.CROUP NFS UNFfS
who does such work himself our through hisown employees,provided that such
improvements are not Intended proffered forsale.If,hmveveq thebullding or TOTAL; .S
ImproverrenHssoid within oneyearofcomplMion,theowner-builderwlll have
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
n L as at of the property,am exclusively co,hu ing with limned PERMIT ISSUANCE
contracture to mnatmet the project(Sec.7044,Business and Professions Code:
The 11
Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA)
Wilds or Improve thereon, and who contracts for such piejecn with a - FEE SUMMARY
c7➢flanor(s)0censed pursuant to the Contractors License Law. RACK FLOW PROTECT.DEVICE
LJ I am exempt under Sac. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,CONI. OUTSIDE FFIN
SANITARY Y N
• Owner Date RECEIPT .
WOR"AN COMPENSATION DECLARATION FIXTURESI'ERTRAP SCHOOL TAX Y ,N•
I herelry af(Irm that I have a dertlflrate of consent to eel(-Insure,ora RECEIPT N
nitrate of Workers'Compereatlonlreunnceoracertlfledmpythereof(Sec.
3800,Lab CJ CAS EA.SYSTEM-1INCA 0IJTLE75 PARK FEE Y N
1'oliry N_ REGI=- X
CAS PA.SYSTEM-OVER 6(EA)
Com any ' BUILDING IV15.0 ' ECS
hereby GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFE I'V'S
Certified copy Is(ikd with the dty Irepenlon divlalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200h7. Date Reed t41
(rhissection need not be completed if the permit Is forces hundred dollars
3100)orlass) lWATER HEATER VO/VENT/E.EC7R - ENERGY FEE Y N
performance comfy that in the perfounce of the work forwhlch W permit is peris Issued,
I shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Worken'CompLnmtlontawsof California.Date - PAID
0 Z Applicant NEW RE9IDENTIALPLMB._SOFT. Date Recei of
Z O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you
I"' should bemm subject to the Workers'Compensation provislmeof the Labor TOTAL:
CC N Code,you must forthwith comply with such providers mthIs permit shall be a
W > deemed revoked. B
CONSTRUCTION LENDING AGENCY SEISMIC FEE
� —aZ Thereby ffi orNfahatich al thiacoretIsboatld(i e. aq7,Cia. .) perform- TOTAL: '- ELECTRICFEE ,5
ance,of Lenderthework(prwhlchlhbperMtIsIsaucd(gee.3097,Civ.C.) PLUMBING FEE 1-G7
O Lender's Name
LL I<naarapddens QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icedifythat]have read this applimtlonand Matethat the above Information -'a
O W iscomact.!agree to comptywith all city and county ordinances and Mate laws PERMIT ISSUANCE i it FEES PAID:
} U) relating to building construction,and hereby authe cue representatives afthis
H Z city to enter upon the above-mentioned property for Inspection purposes. ALIFRORADDTOMECH. ,
(We)agree to save,indemnify as d keep harmless the City of Cu pert Ino - Date Rmci tN
against liabilities,judgment,"sand expense which may In any wayaccrue AIRHANDLINGUNITC17010,000CFM) SUBTOTAL:
;lest old CRy In consequence oft gra i gof this pertnI `
3 U AIR HANDLINC UNIT,(OVER 10,LYIO CFM) CONSTRUCTION TAX ;ill.,
igv not Applient/Contractor Da RXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(uture building occupant store.,handle hazardous HEATING UNIT(TO 100,000 BTU) Date. Ree ' tN • 3
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I I,iihh and Safely Code Section 25532(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
Fj Ye No
WBl the applicant orfutum building occupant use equipment or devices VENTILATION PAN(SINGLE REBID) - ISSUANCE DATE
which emit haaardous air contaminants as defined by the Bay Area Air - �•
Qua lity Me negemnt Dist d"2 BOILER-COMP DFB'OR 100,000 BTU) ;so Y
PYes No Q�r\
• have read the hazy pus materials requirements underCha pler 6.95 of BOILER-CAMP(OVER 100,000 BTU)
the California Helth k Safety Code,Sectio®25505,25533 and 25536.1 a
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECIF1. SQ.PT.
"Feasibility to notify the occupant of the requirements which moat be not
prior to Issuance of a Certificate of Occupancy.
Owner or authorimd agent - Data - VCJV'VIN\�O�-1C;
TOTAL: g;� ISSUEDBY
OFFICE COPY
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