23497APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
'
Building Protect Identification
Building Address:.
PERMIT NO.
loLet 6 olu v
23497
weer Vng- ` 2 Phone:
CITY OF CUPERTINO-BUILDING DIVISION-
- APPLICATION /PERMIT
p� y —"7
—\ se -TL•
Contractor's Name: Li Nm
BUILDINGFLECTRICAL-PLUMBINGMECHAMCAL
CATEGORY
CONTROL p
Architect/Engineer. I.
GA4
-
.. .,...
'=,BUILDING:PEFMITINFO
c`gTy '' BLECTRIrTERINIT
"
Address: -
-
PERMITISSUANCE
❑ ❑ 1:1LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(mmmene-
leg with Section 7000) of Division3ofthe Busl.essandPmtesslonsCode,.nd my
homes Is in full force and affect.
LicenseCie. Lle.M
APPILANCESRESIDENTIAL
.JOB DPSCR8710N
PANELS -
Date Contactor
UP TO 200AWS
L
701-1000 AMPS
ARCHITECTS DECLARATION'
I understand my plana shall be used as public records.
Licensed Professional
OVERIOOBAMPS
TfR AREA
�j.�ffC I•ice,
,• =J=,
$/SQJr.
SIGNSELECTRICAL
OWNER -BUILDER DECLARATION
I herebyaf(Irrnthat lam exempt (romthe Contractors License law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to cerutmct, alter, improve, tlereaelish, or repairGAT
anystructure priorto its hareance,alsomquiresthe applicant(or such permitto
file a signed statement that he is llceosed pursuant to the provisions of the
Contractors License law (Chapecr 9 (commencing with Semon 7") of Divi-
eion3of the Business and Professloru Code)orthat heleexemptihere
the basis for the alleged exemption. Any violation of Section n7031.5 by any
applicant (ora permit subjectatheapplinm to a civil penalty of not nrethan
five hundred ..rewnerofthepr.
❑I, as owner the property, or my employees with wages thele sole
(•/
qty/,] !� II
/O
SPECL3LCIRCUIT/MLSC <�
TEMP METER OR POLE INST.
POWER DEVICES • s
SWIMMING POOL ELECTRICfromand
, VALUATION
OUTLETSSWITCHESFIXTURES
NEW RESIDENTIAL ELECTR �'hT'
S[pIURS
TYPECONSTRUCTTON
jmPr-II ork, andthe s noommoded r d for
ask (Sec.
Se .70K Etude
La. sok (notapply Bu sinessandf
Code: The
Code:The License Law
property or Imprvesthemon
docsnotapply torkowner ofpropertywhobuilds orImprovesiherroRand hat such
owns.
whodoementsaanet
OCC. GROUP
RES. UNITS
intededorough ffered If,ho neertheb buildingor
Improvements ithindneyearfcomprsale.I(, honer-builderwillhave
improvement bsoH within he did et Wild rovehe fo purposerwillha e
en o(proving that he did no[bulld or Improve for purpose of sale)
as owner of the property, am exclusively contracting with Ilcensetl
ca m cons, ruct.the project (Sec. 7094, Business asci Protessiore Cotle:
Fild.
TOTAL:
QTY, ;'.''.PLITII'[$IN4'PF�$T•IF]' ,,; FEE,;`
-��
FLOOD ZONE
APN
pFRMIT ISSUANCE
tractors License Law does net apply to an owner of property whoALTER-DRAIN
r improves thereon, and who contracts for such pSojects with a
co Lt[aetor(s) licensed pursuant to the Contractor's License Law.
ec
LL I am exempt under SB & P C for this reason
&VENT- WATER (FA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY•, -
Owner Date
DRAINS FLOG ROOF,
R AREA, GOND.
FIXTIBIE. PER TRAP cur^^
SANITARY Y N
BBC=#
WORK MAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent d spythsure, ora
olWorkere'Camperuatlon]nsunnce oracerti(led copy thereof (Sec.:
SCHOOL TAX Y N—
RECD, R
GAS EA. SYSTEM -1 INCAOUTLETS - -
PARK FEE Y N
RECEIPT q
3800, Lab C.) �
3800,aftifLah
Policy p
Com any
GAS EA. SYSTEM -OVER 4IRA)
BUILDING DIVISION FEES
copy is bercbyth the nished.
Certified
❑Certified copy V flied with the city Inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
GREASE TRAP
CERTIFICATEOP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlssectian need not be completed If the permit bfor one hundred dollars
($1I0)orless.)
]certify that o the person
I shall not employ any person f any manner so u to berome subject to the
anynce mannerhe work so as to become
eesubjrmit c Issued, the
W plica'Compensation Laws of California. Date _
Applicant
NOTICE TO APPLICANT: after making this Certlfirabeef Exemption, you
PAID
Date ReCei t#
SEWER -SANITARY -STORM EA. 70017.
WATER HEATER W/VENT/ELPCTR
ENERGY FEE Y N
-
PAID
Date Recei t#
WATER SYSTEM/TREAUNG
RESIDENTIAL PLMB, SQJIT.
e
shwld become aubjectmthe Workem'Compeneatlon provisions of the Labor
Code, you must forthwith comply with such proNeions orthis permt shall be
deemed revoked.
- D
TOTAL:
BUILDING FEE
FEE - -
ELECTRIC FEE
CONSTRUCTION LENDING AGENCYSEISMIC
I hereby affirm that there B. construction lending agency for the pedomr
ance of the work for which this permit is Issued (Sec. 3097, Civ, Q
]soars Name
Lender's Addreaa
I certifythatl have read this application and state thaiiheabovein(ormatlon
MECHANICALtPERMIT `�'•.�E. �
NG FEE
NICAL FEE
is correct. Iagreeto comply with ail tltyand county ordinances and nate laws
to building constactlon, and hereby authorize representatives o(ihls`citytoenterupon the above,humdoned property for trupectimpurposes, -
(We) agree la save, indemnify an d keep harmless the City of Cupertino
linbilltica, judgments.9...d expenses which may In anyway acerae
said City in consequence of the grant' of this penMt.9Z
PERMIT ISSUANCE
ALTERORADDTOMECH.
:FEES
D:relating
Receipt#.,.Inst
AIR HANDLING UNIT(TO 10,000 CFM)
$U$TOTAL'against
AIRHANDLING UNIT (OVER 10,000 CFM)
UCTION TAX
Si ren Apt / ontraetor Dame
E(HAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
- AZARDOUS MATERIALS DISCLOSURE
Will the applicant or flutter building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Health and Safety Code Section 75537(a)7
❑ Yea ., ., No..
Date ReCei t#
HEATING UNIT (TO 100,W0 BTU)
HEATING UNIT (OVER 100,000 BTU)
TOTA .
ION FAN (SINGLE RESID)
ISSUANCE DATE -
A s„
M (i
7understand
I�-IISj /�raa�responsibility
Cll/ 99prior
VI W-
which emit hazardous air contamtna his as deflned by the Bay Area Air
Qu hty Management District?
Will the applicant or lure building occupant use equipment or devLMSPHOILER-0O3MP
PYes ['']� No
havereadthe been �nusmatcrialsrequlrementsunder Chipter6.95of(OVER100,0W
Glifrnia Fleal[h&Safety Code, Semons 25505, 75533 and 75539.]A11p
that !(the building does sat currently haveatenanq that it is myENTIAL
to notifythe occupant of the requirements which must be met
to issuance of aCertifirate o(Occupancy. .
MP QHPOR 100,0(0 BTU)
BTU)the
MECH. SQ.FT
GUYCf3
ISSUED 8Y:
..
Owner or authorized agent Date
,
TOTAL:
OFFICE COPY