24178 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
1,90 S;Z Bu Rn¢0 Protect IIdentificatiIdentification ilot n PERMIT Nn
4 1 7 p Building Address:,
Z
.nera name:. Phone: v APPLICATIONSUBMITIAL DATE
VAY v,+IS Nhv
973 1903 CITY OF CUPERTINO-DUILDINC DIVISION
CoolmF�otoF'a Name: _ Ljic.yN : APPLICATION I PERMIT,
ILL'" reY C:;7-.P !9 BUILDING-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY 'I CONTROL N
'. Archilect%Engineer: Llc.No:- -_ L -
t BUILDING PERMITiINFO. ','
,QTY; ELECTRIC PERMIT. � +•FEE, �I n.�uma mrx.,t-
A`-"-'
PEEN IITISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION I -
I hereby afcn that lam licensed under provisions ofChapter9(commenej APPUANCEB-RESIDENTIAL ( 'JOB DESCRIPTION
ingwlthS dion70W)af Divislon3ofthe Budnessand ProfesNOnsCode,and my „ `• ,peW
licenxlsinfull deffect. PANELq
LkenygG as N LIe.N 5e(L��) 7
Date CHITEC7r I^at ]SIP' n S
ARCHITBCP RATION
z ]understand my ph+a ahaB be used d as u public records. OVER 1000 AMT'S F� N4,.`pp � _ p IS�Q. .FLOOR AREA 9/SQ.Ff'.
k o Licensed Professlonal SIGNS ELECTRICAL 1 . I tl V LI _ �I.m. �/ I
�Q
OWNER-BUILDER
ro DECLARATION SPECIAL Cl2CUIT/
Ihercbyaffirm that]cam exemptfromthe Cunt,actors License law for the 1 a
following reason.(Section 70115,Business and Professions Code:Any dty or
02'-• TEMP.METER OR POLE INST.
Pg county which rcquircsa permit toconstruct,alter,Improve,derrtolbh,orrcpalr DATE
$$q �� anystrvcturcpdorto its Issuance,alsomquiresthe applicamfor such permit tai POWER DEVICES
O Ole a signed patement that he la licensed pursuant to the pmv.....of the
3 w Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi.
sion3ofthe BuslnemanAPmfessiomCWe)orthathei, xempttherefromand SWIMMING POOL ELECTRIC VALUA=�L l(j4,
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHFSHXTUREB / O
004
applicant for a permit subjects en the applicant to a civil pe icy of not room than L
$ five hundred dollars($SM. NEW RESIDENTIAL ELECTR FI.
❑Las owner of the property,or my employees with wages m their sale SQ' I STORIES TYPE CONSTRUCTION
CT6 compensation,wOl do the work and the structure E not Intended or offered for
❑ axle(Sec.7014,Business and Professions Code:The Contractors License law
Y$ does not apply to an owner of property who builds or improves thereon,and I
EEEEEE who does such work himself orthrough his own employees,provided that such tXC.GROUT' REq.UNITS I
improvements are not intended mattered forsale.If howeveq the building of l TOTAL:
Improvement issold withmoneyearofcompletion,theowner-bullderwlll'. +I LEE t
tkk«�araenofproving that he did not baud orlmpeve forpurpose ofwb.). (QTY. +( PLUMBING PERMIT FLOOD TONE p APN
L1 L as owner of the property,ate exclusively contracting with licensed PERMIT ISSUANCE I N
contractors to mnslruct the am (Sec 7044,(S 7044,Business and Professlanu Code:
The Contractor's License Law does not apply to an owner of property w'.. ALTER-DRAIN&VENT-WATER(G)
Wilds or improves thereon, and who contracts for such ptojecta with a I ,FEE SUMMARY
C16,"or(s)licensed pu nuant to the Contractor's License Law. BACK FLOW pROTEC7.DEVICE I
LI I am exempt under Sec. B &P C for this mason t 01 msrpn urns
DRAINS FLOOR ROOK,AREA,COND. I SANITARY Y N_
Owner _ Da`• RECEII'N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP - SCHOOL TAX Y N
hereby affirm that I have a certificate of consent to se161nsure,or a I RECEIPT IN
certificate ofWorkerd Compersation Insurance or a certified copythereo((Sec. (GAS G.SYSIFM-1 INC.40UTLLTS I PARK FPIT Y N
38OO,Lab C.)
Policy# RECEIPT J!
Com an. n - (CAS EA,SYSTEM-OVER I BUILDING DIVISION FEES
[CeEd copy is hereby dwith thehed. (GREASE/TNDUSTRL WASTE INTERCEPTOR I PLANCHECICFEE
�fled copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP I PAID
COMPENSATION m becamm INSURANCE SEWER-SANITARY-STORM G.200hT. I Date Recci t#
Rhie section need not W completed the permit b for one hundred dollars D
($1 W)or leas.) NERGYFEE Y permit WATER HEATER W/VENT/[LCCTR
I certify that in the performanmofthe work forwhich this pedt is
ued, I —
'I shall not employ any person In any^ands,ro a to became subject to the WATER SYSTEM/TREATING I
Workers'Compensation laws of California.Datr PAID
Q Z Applicant I NEW RESIDENTIAL PLMB._SQ.FT. I I Date Receipt# '
'Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you _
O sh.ld became subject la the Workent'Compensation provbiam of the Labor I TOTAL:
~ y Code,you most forthwith comply with such proviskme err this permit shall be I (BUILDING FEE
� j deemed revoked.
III o CONSTRUCTION LENDING AGENCY ' + SEISMIC FEE T q
I hereby affirm that there is a coustmdlon lending agency for the perform- I iLECTRIC FEE
O anm of the work for Vht�permit I,unded(Sec.3097,Cie.C.) TOTAL �PLECTRIC FEE
0 Iandcr's Name I/VV'•
IL F Lemi—Addmes (QTY. , 'i MECHANICAUPERMIT' - FEE
U Icertifythatl have read this applicationand stamthattheabovein formation
O a Isconect.l agree to complywlth all cityand countyordloances and state laws) PERMIT ISSUANCE I FEES PAID:
r relating to building constitution,and hereby authorize representatives ofthis - --
Zcity to enter upon the above-mentlonod property for WpeRion purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino I Date Receipt#
U agaimtllabllitlen' dgments,cortsand expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,ODO OEM) I - SUBTOTAL:
against Bald i one ..f.tsF�r�canting of this It
" :r! ' s_97 AIR HANDLING UNIT(OVER 10,(X10 CrM) I CONSTRUCTION TAX
Signatureo(Appliant/Contractor pales (EXHAUST HOOD(W/DUC'1) I +CONSTRUCTION TAX PAID:
HAURDO US MA IALS DISCLOSURE
Will the applicant or future bull oceapant score or handle hazardous HEATING UNIT(TO 100,010 BTU) I I ' Date RCCCIDt#
materials,defined by the Cupertlno Municipal Code,Chapter 9.1 2,and the !
Healthand Safety Code Be 32(.)7 HEATING UNIT(OVER 100,000 BTU) I TOT//]
❑ Yes o
Will the applicant or turn building occupant use equipment or devices I VENTILATION FAN(SINGLE REBID) I ISSUANCE DATE '
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DuMct7 BOILER-COMP OHP OR 100,000 BTU)
e� 4havee read the Nazar duds requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) I NN +
the California Health&Safety Code,Sections 25505,75533 and 25534. I P" q '
undvmta nd that if the building does not mrrcntly have a tenant,that It E my NEW RESIDENTIAL MECH. SQ.FT.I V
responvbllity to notify the oav pant of the mquircments which most be met —//�x�1''''CS(P
poor to lssmnce Certificate of cupancy. .n v`Fa �G
Owner or authorized agent / Date II ISSUBD BY: - I�
TOTAL: I I t
OFFICE COPY ~