19670 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALLPOINT PEN ONLY
Building Pm'ed Identification PERMITNO.
Milding Address: - - 19 6 7 0
22944 Inn down Road Cu Inca CA 95014
mra ante: Phon
Lyna Moffett 255-4338 CITY OF CUPERTINO-BUILDING DIVISION
Contactor's Name: Lle.No: APPLICATION / PERMIT 2 Z�qd
Bob Gere Maso 265509 BWLDINO-ELECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL#
Archlted/Engineer. Llc.No: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaf(Irmthatlamticensedunderprovisionsof Chapter9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith SecHan7000)of Div e.3ofthe Businsssand PmfetdonaCode,andmy
license la in fn Tnex, effect. PANELS
License Class 1.—L7 Gc.k 265509
Date —Contractor
my Chime Repair
ARCHITECPSDECLARATION OVER
A
p�p�uOQCZOC iundentand my plans ehaBbe used sspublic remrds GVER 7000 AMPS SQ.Fr.FLOOR AREA g/SQ.Ff.
FL o U Licensed Professional SICNS ELDCTRICAL 3.
G�6 OWNER-BUILDER DECLARATION SPECIAL CrRCUIT/MISC
7 f,�4 l herebyaffirmthat l am exempt fromthe Contradorb License Law frnthe -
pppp following reason.(Section 7831,5,Business and Professions Code:An d or
Fe' county which requima permit toconstru"ter,4npreve,demlbh,or repair TEEMP.M.M"MORPOLEINSF.
any structure prior to Its lasuance,also requite the applicant fm such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provblons of the
0�
Ow Conlract.e.License Law(Chapter 9(commencing with Section 7").f Divi-
slon3.flhABusiness and Profeselom Code)orthat he b exampVALUATION
the
SWIMMING POOL ELECTRIC
yt S the basis for the alleged exemption. Any violation of Se Pon 7MIS by anyOUTLETSSWITCHESFlX'R7RF5 0
<++ applicant for a permit s I,Ictsthe applicant to a civil penalty of not mem than than
(I undreddollars(swm. 1 565.00
uL as owner of the ro NEWRESIDENTIALELECTR SQPr. MRIEScompeTYPE CONSTRUCTION
�n p party,or my employees with wages a there sole
.]a(Se 7044,willdothework and the stCode;
dure braintended proffered for
0 doe es nota064,to alnowner Professions Co builds
or improves
License law
S� whodotaitach oanownerofthroug hisonemplrlmproovidedthatsud OCC.GROUP - RES.UNITS
whodvem ntsworkhimse intended
hisors emplayeemprovidedthatsuor S--�
Improvementaaanalntended earnfe dforsile.the owner-) tilderwdingrn TOTAL: Q 2
ImprovenenHswld wlthinoneyeamfcamptetlon,lheawner-bullderwlll have `J
tl(g,Zurden of proving that be did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE-
contracton to construct the project(Sec.7064,Business and Professions Cade: '
The Contractor's License Law dean not apply to an owner M property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improve therer
on,and who cornets fa such ptojvd -
s with a .FEE SUMMARY
cgR(1+ctar(s)BansM pursuant to CantndoYs License Law. BACK FLOW PROTECT.DEVICE
L�I am exempt under Sec -' B&P C for this reason
OUTSID
DRAINS R, AREA,COIF FLOO ROOF, SANITARY Y N
• Owner Date RECEIPTM
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
®I hereby affman that I have a certificate of consent to self4mom,ora RECEIPT Y
certificate OfWerken'Compensation Insurance or a amlfied copy thereof else.
, CAS EA.SYSTEM-1 INC.4OUTLETS PARK FEE Y N
3800Tab C.I
Policy WCG 20677-C - RECEIPT#—
GAS PA.SYSTEM-OVER 6(EA)ram at -
at.]F1TIA BUILDING DIVISION FEES
Wed copy b hereby tthe cid. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
C
CeedBIM copy b filed withh Ik city inspection division.
CERTIFICATE OF EXEM PFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA-XIOF1• Date Recei tri
(Thi.seditm erred not be completed if the permit b forme hundred dollars
(8100)rnless.) WATER]{EATER W/VEM/EL1L:'1'R ENERGY FEE Y N
I mrtlfythat N issued,the performance of thework forwhich this permit is issued,
I shall net employ any person In any manner no as to become subject to the WATER SYSTEM/TREATING
Workers Compensatlon(aws of California.Date PAID
ZZ Appllcant - NEW RESIDENTIAL['LMB. SQ.FT. Date Recei t>t
O NOTICE TO APPLICANT:If,after naWng this Certificate of Exemption,you
I" should become subject lm the Wmkers'Cempensatlon provision of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this pentyl shill be BU x
W > deemed revoked.
CLCONSTRUCTION LENDING AGENCY SEISMIC FEE 570
I hembyaffirm that there is;a construction lending agency for the perform- ELECTRIC FEE
7 O an.ofthe warkforwhlchthb permit b Issued(Sec.3097,Civ.C.) TOTAL:
4ndels Name PLUMBING FEE
LL f- Loodne.Addrcas QTY. MECHANICAL PERMIT ITE MECHANICAL FEE
OW ImdifythatlhavereadthbappllmtlonaMdaFthattheaboveinformatlon
a Escorted.]ago to complywith all city and county ordinances and slate laws PERMIT SSUANCE FEES PAID:
N relating to building censtmction,and hereby authodae repreeentalives of this -
city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. -
? Me)agree to save,indemnify an d keep harmless the City of Cupertino - Date Recei t#
V agaWt liabilities,Ndgiara,matsand expenses which may in anywayamne AIRHANDLVJG UNa ero 10,000CFM) SUBTOTAL:
against id City in consequence of the granting of this permit
//- ���0 'AIR HANDLING ND'(OVER 10,000 CFM) - CONSTRUCTION TAX
Slgnatureof Applianl/Con ctrn Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU) Date Recei tin
material as difired by the Cupertino Munidpal CMG Chapter 9.12,and the
I ealth and Safety Code Sedion2S532(a)I HEATING UNIT(OVER 100,000 BTW TOTAL: �
rl Yes No
Will the appllant or re,No
use equipment or devices VENTILATION FAN(SINGLE RISID) ISSUAI�LC�g41TE
which emit hazardous air contaminants as defined by the Bay Arca Air I�E'4Mtlt�
. Quality Management District? BOILMOOMP OHPOR 100,000 BTW
n❑ Yea II��II No 'I ;7
IAave read the haaal N materials requirements underChapler 6.95 of BOILER-COMP(OVER 100,000 BTU) . ('t•� •^ ,L 1990
the GRfemia Health&Safety Code,Sections 75505,25533 and 2:534.1 •y
understand that if the building don not currently have.meant,that it is my NEWRFSIDFNTIALMECH. SQ.FT.
mapoaibility to notify the occupant of the requirements which must be met 4,�
Pd issuanceofaCattfiateofOcrapanry. Clay fif ffinM'hllo
Owner or authorized ager Data - TOTAL: V ISSUEDBY: V v C-Iwkovi--y--��Y
OFFICE COPY