21263 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PIR.WT NO.
Building Address:
19 la L V Ptl L\ 21263
wners Name: one: A h b0bMLI LALA
CITY OF CUPERTINO-BUILDING DIVISION
Ko tractoraName: Lic.Na: APPLICATION / PERMIT
a+ tt-j A ,-� v 5 Lt BLTLDItiC-ELECTRICALPLUMBINGhIECHA\7CAL CATEGORY Collrl I-.av(1
Architect�/En.gneer. }�c b �-�I .J s
. t"iL007C�Cp�u��( ��D� 'I�- a a';= ass > a••- a i;
BUILDING PERMIT INFO +
QTv; ;:- ;ELECTRIC PERMIT, _ FEE - L - 'x-'-
Address: PEL'vITISSUANCE I�s ❑ ❑ ❑
LICENSED CONTRACfOR'S DECLARATION
Iherebyaffbm that l am llcemed under pamabroms of Chapter I(commenc APPLIANCES RESIDENTIAL JOB DLSCRI['FION
ingwlth Section7000)of DMdoa3ofth Businessand Profssime.Code,and my
license is in fuI fo and A.\'
effect O� D PELS
Llecnsa Cl LIc.N
Date Contractor 2p TO:iio AM r 1
AAC DECLARATION OVER IOW AMPS 1 SQ.IT.FLOOR AREA 5/SQ.FT.
20
I understand my platy shall
g be be used s pubilcrccords r
C U tj Licensed Professional SIGNS ELECTRICAL Scx")
LP
6 OWNER-BUILDER DECLARATION \
'v: y SPECIALCIRCLIT/M
f., Z I hereby affirm that l am exemptfromthe Contractor's License law for the
)Z-39 foiowing reason.(Sectio,7W1.5,Businevand Professions Code:Anydtyor TEMP..NEIEIt IPO IN
;n4^ mmiywhichrcgWresapermittocommo,alteilmpmvidemlBh,ormpalr
)1 any structure prior toffs issuance,also requires the appliont for such pemdt to POWER 1
c < file a signed statement that he b 1lreneed pursuant to the provisions of the
'O^J Contractor's License Law(Chapter 9(commenn with Section 7000)ofDivi-
%OS slon3ofthe Buslnessand Profesb
s(onsCode)orthat heexre
empttheGumand SWLNJ9Is E C ` VA VALUATION
'2 the basis for the alleged exemption. Any violation of Section 70115 by any UTL TC
applicant fora permit subjects the applicant We civil penalty Dior morethut � ` O a
WCLEC
five hundred dollars(S500).
SQkT. STORIES TYPE CONSTRUCTION
z m L,as owner of the property,or he employes with wages r their sole
..'?Q compensaHon,willdothe work andthe s[ruciurebnoHntended or offered for
rC C sale(Sec.7036,Business and Professlmi,Code:The Contractors Lt..law s
dos
not apply to an owner of property who Wilds or impress thereon,and I l OCC.CRO(IP RES.UNITS
who dos such work himself or through his own employees,provided that such
improvements are not intended oroffered for sale.IL however,thebudding or j TOTAL:
improvement taaold withmone yearnfcompletion,the owner bu0derwBlha .T ..-.. �.
thjgkurden of that he did not build or im rove for of R" y
Lf proving P purpose QTY. ..:%,v+PLUMBl PE MITu .: .y IZEE4, FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed PER.MITISSUANCE 1
contractors to construct the project(Sec.70K Business and Prolessiom Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER MA)
or Improves thereon, and who contrztls for such p\ojem with a a;a
co�nt(actors)Bansed pursuant to the contractors License Law. I. :SS'b,hL a'I.FEE,SUMMARY I�r
u I am exempt under Ser- B &P C for this reason BACK FLOW PROTECT.DEVICE OLITSI OF FEES
- - - -
DRAINSFLOORROOF,AREA,COND. SANITARY Y N
"•Owner Date RECEIPT N
WORKMA.s1COMPE145AT10NDECLARATION p7y.NRFS-PE2 TRAP SCHOOL TAX Y_ N
F-11 hereby affbm that I have a oertl0cate of consent to sell-Insum,ora RECEIPT N
certificate ofWorkeri Compensationlmuranca ora certified copy thereof&c. GAS F.A.SYSTTM-]INCA OUTLETS PARK FEE Y N
3800,Lab q RECEIPT x
Polity N GAS EA.SYSTEM-OVER<(FA)
Com aBUILDING DIVISION FEES
[Certnyified copyb hereby furnished. CREASE/L\DUSIRL WASTE INTERCEPTOR PLANC ECK FEE
�CertJcdcopy is filed with the city inspection division. A2 / J ^
CERTIFICATE OFF EMIFTION FROM WORKERS' GREASE TRAP PAID (/" �f� o
COMPENSATION LNSURANCE SEWER-SANITARY-STORM EA 200Ff Date Rccei t#
(This section need nor be completed If the permit Is for one hundred dollars
(SIM)Or less.) WATER HEATER W/vExf/ELECTTt ENERGY FEE Y_ N_
1 codifying mine perorn
rancaof the wawNm
rk forch this peit Is Issued,
1 shall not employ any person in any manner so as to become subje t to the WATER SYSILM/IRFA'IING
Workertcampensaeionlawsafaufmno. Date PAID r0
O Applicant Date ROcei t# 7
Z PP NEWRESTDFNTIALPLMB. SQFT.
Z O NOTICEca APPGCAtote, orkem'ame k ompensationng this lateo(Exs of
Labor TOTAL: I 5
W Code,you most forthwith comply with such provisions or this permit shall be BUILDING F
deemed revoked. 2 s
W > CONSTRURION LENDING AGENCY SEISMIC FEE
CL f] Iherebyaffirrn that there b a construction lending agency for the perform- ELECTRIC FEE
TOTAL:
70 arm Lender's
work whichfhbperMtbiuved(Sec 3097,CIv.C.) PLUMBING FEE
LL O Lender's Name • i;>MECHANICAL'�PEAMIT•ar ,;,+•FEE;.),
LL H lender's Address QTY - - MECHANICAL FEE
U Iretli.lag hno madthuap plicationand dcounte thattheordina ccs and stat laws
tion
O w uco .Iagreetocomplywithall rityandcountyordinancsand9atelaws PERMIT ISSUANCE FEES PAID.
} 1 it to building controction,and Mrebyauthome represtruiuvesm,it.
't toenteru the above-mentioned forW ion ALTER OR ADD TOMECH.
F Z Y upon keep ha Pert wrnupe Date Receipt#
_ 4.,al
)agree to save,Indemo San d keep harmless the City of Cupertino AIR HANDLING UMT(1'010,000 CFM)
llabilltls,jodg b,cosh swhrch may firs anywa accrue SUBTOTAL:
saidCity fine fi anting of tFla permit.' aRHANDENC VNIT(OVER 1o,tnocFM) CONSTRUCTION TAX
gre of App ant/C ntracmr ace EXHAUSTHOOD(W/DUC7) CONSTRUCTION TAX PAID:
HA DOUS MATER IALS I)ISCL SUR'
Will the applicant orfumre build Ing«cu pant store or hand le havrdous IfEATING UNIT(TO 100,000 BTU) Date RBCeI t#
muter ail as defined by tM Cupertino Municipal Codi Chapter 9.12 and the
Health and SifdyCd,,$edjon 255320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant or urc buildingompam use equipment or devices -ILLATION FAN(SINGLE REBID) ISSUANCE DATE
` • which emir hazardous air contaminants as defined by the Bay Area Air
Quality Managcmen 7 BOILER-COMP OHP OR 100,000 BTU)
4Yes Na
have read the bazar snuterialsmquimm ntsunder Chapter6.95uf BOILER COMP(OVEt 1W,0008TU)
t orn' "alth&"MCode,Section25505.Z5133and25i33. 1
ndersundihatrfihe bu diegdof curtemly haveatanantMt iib my NEW RESIDENTIAL\ECH. SQ.Ff
apo bility io naify a Pik of rhe requirementswh ch mu t be met '�,y.,rs�
prior is seance Dice rt'�ate .aF rX
ncr or autho iced ge Dale TOTAL. ISSUED BY: V../1 1ftu��= „ l R'
OFFICE COPY SLY