19681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Address:lu a 1e ATc�c/ 19681
Marae: �p hone:
aZ2 14 �,� y P�(l�..A/G( CITY OF CUPERTINO-BUILDING DIVISION pp
G ° Lie No- APPLICATION I PERMIT 3 - C d
a BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Englmee Lie N
QTY ELECFRICPERMIT FEE ,,.�..__//,,BUILDING PERMITINFO
Addrcec PERMITISSUANCE �Y/� ❑ ❑ El'LICENSED CONTRACTOR'S DECLARATION LL��
Iherabysfftrmthat l am licensed under provisions of Chapter9(commune. APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of Divls1m3 ofthe Bualnessand Profesdiom Code,and my 4
11=1sln rdeffetl. PANELS
Llan ® Lle
Dat ARCHITECTS
G
ARCHalline sedaspDECLARATION 701-1000 AMPS
Iundentand yplamdhall be used mpubecrecords. OVER 1000 AMPS w, l'�I.OQIIARgl1� ' /SQ FT
!i Licensed Professional SIGNS ELECTRICAL INA�aA+` L C I.I
<<�6. OWNER-BUILDER DECLARATION SPECIALCIRCU[T/MIST RYR P.0 TE
7p, 7a Ihrmbyaffirmthatlamexempt fromthe Contractor's Lf...lawforthe
po following reason.(Section 7031.5,Business and Pretensions Code:Any city or
Z Fttocerestruct, TEMP.METER OR POLE INST.
pt ceuntywhire requireaspersemalsorequirstheaprovgdemouch,or repair .- /
q' any atsucturctatemeprierto itehat he Is licensed
pursuant Illmnlfw ouch permit to POWER DEVICES ,e,—�
PJ file a signed statement that he V Ikensed pursuant to the provhions of the
3w Connell'.License Law(Chapter 9(cemmencing with Section 7IX10)of CIA- VALUATION
SOS elan 3 ofthe Business and Psofenlom Code)or that he is exempt therefroma ad SW1MMINGIWL ELECTRIC
O the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHESHXTURFS f /C/ .46
applicant fora permit subecatheapplicant to a civil penalty of net more than J (D
five hundred dollars(5500).
�n ❑I,as owner of the property, NEW RESIDENTIAL RLECTR_SQ.F'f. STORIES TYPE CONSTRUCTION
p perry,m my employee with wage a thele sole
compensation, and
and the swcture is not Intended or offered for
dale(See.7M4,to a now and f property Cade:The Contractors License Law
$ doe not apply torn owner of throng hiswho
nemsarlmpmovidedves reoryand OCC.GROUP RES.UNITS
who dmsuchwork hlmaeVorlhrwgh Msownempigee,provided that such
improvemdnb are not Intended oroffered for sale.If,however,thebuilding or TOTAL,-
Improvement
OTAL:Improvement issoldwlthinaneyearofcomplation,the owner-bullderwlll have
UlLtluden of pawing that he did not build or bnprove for purpose ofsaleJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj Las owner of the property,am exclusively contracting with licensed PFRMII'ISSUANCE
contractors to construct the project(Sm.7044,Business and Pretensions Code:
The Contractor's License Law does not apply to an owner of property who ALM-DRAIN VENT-WATER(EA)
Wild.or Improve thereon,and who contracts for such pka)ects with a
cgIltT+ctor(a)Beamed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ 1 am exempt under Sec B&P C for this reasonOUTSI OF FEES
Owner to DRAINS.FLOOR,ROOF,AREA,CONT. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT R
[3,hereby affirm that I have a artl0ate of consent to self-Inwre,or a IlXII1RES PER IRM SCHOOLTAX Y_ N
conifieteof Warkari Compensation Wuranmmaadi( dmpythemo((Sec. RECEIPT i7
3800,lab C.) qq /� GAS EA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
RECEIPT a
Com GAS EA.SYSTFM-0OVER BUILDING DI VIS ION FE ES
CCertified cop is hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCFIECK FEE e
Certified copy is filed with the city Wpectlon dlvlalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORM EA 20OFT Date Recei t#
(This,sedan need our hecomplated lithe permit I.forms hundred dollars
(fill0)aly that WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
lanotrtify that In the person
forwhich as tobthiomesal[c Issued,
I.lull not employ any person In any manner ro v to become eub)ett to the WATER SYSTEM/TREATING
Workers CompenssUon Laws of California, Date PAID
O Z ApplicaNOTICnt NEW RESIDENTIAL.PLMB._SQ.FT. Date Recei til
Z O h.ldbco esub)CANT:e eller ms Co [leasationlaleo(Exemption,oftheyou
CCCode, ou=st forth ithto co Workers'Comprovisinprovhlomrmit o Lab be TOTAL:
Lb Code, rerrwatfarthwllh comply with such provisions orthb permit shall be BUILDING FEE 1
� 7 deemed revoked.
LU
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafRrm that thea Is a construction lending agency for the perform ELECTRIC FEE
Z once ofthe workfor which this permit is issued(Sec.3097,Civ.C.) TOTAL:
V O Lender's Nacre PLUMBING FEE
14, E Lenders Addrens QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iartily thatl have read thisappliaeon and tlatethat the.bove Information
1 Iscorrcct.I agree to complywlth all city and countyordinarcesend state laws PERMIT ISSUANCE FEES PAID:
�. relating to building construction,and hereby authoriurep—....tiveof this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTLRORADD 70 METH. Date Recel Hf
V _ (We)agree to save,Indemnify an d kap harrrJens the City of Cupertino
against liabilities,judgments,me,and expenses�Yhichmayinarywayacxxue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
agaWtsal ity In consequence a ntl (thio permit
_ice 2 � - AIR HANDLING UNIT(OVER 10,WCIM) CONSTRUCTION TAX
Signa of Applicant/Camras r � EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOeS MATERIALS DISCLOSURE
Ill the applicant the future building occupant Code, hapten lehazardous HEATING UNIT(TO 1PU,000 B11) Date Reel t#
material as defined by the Cupertino Municipal Code Chapter 9.12,and the
I ealth and Safety Cade 32(x)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
F1 Yes No
Will theapplicant orfuturc building ocetpantuseequlpmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous atr contaminant.as defined by the Bay Area At, ����
Quality Management D'frici BOMER-COMP OHPOR 100,DM BTU)
4 yes
o pp ��}} aQpt�ya,„r.t1
have read the hazer ausmatedals rcquirementd under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) MPSIY Up 1VVV
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building don not currently have.tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT.
.Feasibility to netift,t1j.eccupantof the requirements which at be rsrt
rtolssuanceofa rt if of parry.
�, to of (`P. +lino
nercrauthorize gent Date `
TOTAL: ISSI]EDB V
OFFICE COPY