19753 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ewtdi. Prm'ed Identification PE,tMITNO.
Building Address: 19753
.; 1990 E2CEo� (Z�
NachouwnerS Phone: p
-r#FYYj+t?_J }s)ISTS CITY OF CUPERTINO-BUILDING DIVISION
cwerdor'a NamE: Lie.No: APPLICATION /PERMIT
Is Ur 7 t � 7 6 BUfLDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROLM
Archited/Englmeer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE x.7,00 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am hernsed under phrvtdons of Chapter 9(commeme APPLIANCFSRESIDEN1AL JOB DFSCNIFFION
Ingwith Section 7000)ut Dividon3 ofthe Buslnessand ProfessionsCode,and my
Ilcense IB in full f end effect. PANELS /
LlcenseC m y0 Lie-N / �YG37 /""r
Date Contractor 2011000 AMT'S
ARCHITECTSDECLARATION OVERIOODAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
w�w O I understand my plans shall W used as public records.V Fj Licensed Professional SIGNSELFCTRICAL
<�6 cors OWNER-BUILDER DECLARATION
u, SPECIAL CRtCNT/MISC
f„ Thereby a(firnthatlam exempt fromthe Contractor's License Law for the
following reason.5MIon 70315,Business and Prolmions Code:Any city or TEMP METER OR POLE INST.
q�yu9 county which rccryimea permit tocomod,alter,improve,demolkh,orrepair
'e.I anystructure prbrto its useence,alsorequirestheapplicant for such permit to POWER DEVICES
LPs. G V file a signed statement that he is licensed pursuant to the provisions of the
03'�fn Contractor'sLicense Law(Chapter9(crmmencingwith Section 7000)of Divi- SWIM IINGIX30L ELECTRIC VALUATION
p InO� sion 3 of the Business and ProfessiunsCode)or the hely exempt therefromand
Q the bash for the alleged exemption. Any violation of Section 7MI.5 by any m (�
OUTLETSSWITCHESHXTURFS Q,�p / /�r / O
applicant fora permit subjects the applicant to a civil penalty of not
orethan
E live hundred dollars(E500).
Ctii �1,as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTRSQ.FI'. 't STORIES TYPECONSTRUCTION'
s.7a compensallon,w0ldotheworkandthestructurelsnotIntendedorofferedfor ��.00
�G D sale(Sec.704L Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
•..
whodwssuch work hlraeBwthrough hlsawnemploym,prrvldcd that suchOCC.GROUP RES.UNITS
Improvements arc not Intended oroffered forsale.If,however,thrWildingor 1/TOTAL: / 2i
Improvement issold withinoneyearofcompleiogth owner-builderwill have
tFalZurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PE MIT FEE FLOOD LANE APN
L as owner of the property,am exclusively contracting with licensed pggMPp ISSUANCE O
contractors to construct the project(Sec.7014 Business and Professions Code: \ \ T t
The Contractor's Llwnse Law does not apply to an owner of property who ALTER-DRAIN&YFNT.,'--WATER
Wild.or Improve.thereon,and who contracts for such p(cj ccs with a - FEE SUMMARY
ott[actoRec sl Bormod pursuant to the Contractors License Law. CK FLOW PROTECT.
DEVICES
LII am exempt under SB k P C for this readers
NS FLOOK%OF,AREA COND. SANITARY Y N
Owner Date . RECFRTp
WORKMAN COMPENSATION DECLARATION �Tgpls Et SCHOOL TAX Y_ N_
QI hertby affirm that I have a certlfteate of consent to If. so
oraMVRI1\ RECEFr N
aomfleaeof Workers Compensation Wuranorm.certified copy thereof V. 1 ��
3808,Ieb G _STEM-1 WC.10UTLETS ,i PARK FEE Y_ N_
I:DNG DI N
Poliry Y_ G 9 9 CAS .SYSTEM-0VER 6(EA) \ —
BUILDING DIVISION FEES
f ICertified ropy Is hereby furnished. /WD "wA 1NTERcpP.TOR\ PLANCHECK FEE
Certified copy k filed with the city impection division. )
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP 1 •f PAID
COMPENSATION INSURANCESEWER-Sp MT'PRY-S[OR.\i EA. `! 1, Date R=i t#
(this section need not W completed I(the permit V an
(cre hdollarsd dollars
WATER BEATER w/vENT/ 'a ENERGY FEE Y_ N
certify In _
I rtify that the performance of thework forwhich this permit is issued,
I shall not employ any person in any manner so as to become subje d to the WA713SYSTEM/TRFAT7
Worken'Compematlon Lawn of Call(mmla.Dae r..• PAID
O Z Applicant NEW RES DGNTIAL PLMB. QIT. Daft RCcci t#
Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
rW should become,subject to the Workers'Compensation provision ofthe Labor TOTAL:
Code,you most Forthwith comply with such provisions or this permit shall be BUILDING FEE
j deemed revoked.
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there In a construction lending agency for the perform TOTAL: ELECTRIC FEE
7 Z anceofthe work for which this permit b WN097
u (Se,.3 ,Civ.G)
00 I.ender.Name PLUMBING FEE
U. H Lcnder's Addrex QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certify that l have read thin appBceOon and date that the above information
O W is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. 1 relating to building mntruction,and herebysuthorucrepresentativesofthb
(— N city to enter upon the above-mentioned property for inspection purposes. AUIERORADDTOMECH.
? (We)agree to save Indemnify an d keep harmless the City of Cu Perdido Date Receipt#
V
against liabihiks,judgments,costs and expenses w Ich may in any way accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
old sty In con nor of anting t rmit.
y,G AIR HANDLING UNIT(OVFSt10,000CPM) CONSTRUCTION TAX
S' rcat AppIk, o tractor Date EXHAUST I IOOD(W/DU171) CONSTRUCTION TAX PAID:
HAZARDOUS MATER LS DISCLOSURE
rWil'thea licant or Future building occupant store or handle havariuus HEATING UNIT(TO IW,"BTU)
PP B P Date RCCCI t#
nateth.asdefined by WlW Cupertino Municipal Code Chapter 9.12,and the
tlealehandSafetyCad`,SgNo 75532(x)7 HEATING UNIT(OVER 100,O1108TU) TOTAL: /v
Yes t (�¢tun
Will the haxano r tore building occupant by the Bay Area devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit ha Management
air contaminants as defined by the Bay Arca AU oAr
Quality Mangement Lf]�s�VfR�t7 BOILER-COMP Oto'OR 100,000 BTU) C!'UD
4 Yrs stare CTU
have read thch case malcriak requirements under Chapter 6.95 of BOILER-COMP(OVQt 100,fXq BTU) A
the California Health h Safety Code,Sections 75505,25533 and 25534.I n �JJTT
understand that if the building does me currentlyIh.ve a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. r a:U N JU
Ib llitytonotifythe pant of the req which most be men
ort issuance ofa rd too! panty
Ity Ince
cr or authorized agent Date ISSUE s
TOTAL:
OFFICE COPY