20710 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldln I'm ect Identification �/A / / / PERMIT NO. 71
Build Ing Add,7: / gSb �4,7taeI R_ t Y 0 1 1 O
10 ^'�Phone A
L DA 117
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ski -3CITY OF CUPERTINO-BUILDING DIVISION
Lle APPLICATION /PERMIT \r
BUILDING-I3,BCTRICAI.PLUMBINGMFCHAMCAL CATEGORY CONTROL M
ArcIteR/ glneer. LIB Net
QTv ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: —16 PERAIITISSUANCE El ❑ El
CONTRACTOR'S DECLARATION
I hereby aRtrmthat l emlicensei under prewblonsof Chaperg(marrourec. APPLIANCES-RESIDENTIAL TOB DESCRIPTION
ingwith Sectton7DDD)of Dlvision3ofthellusinessand ProfessionsCode,and my
Branae ts In luB d sic,# /ry-�7025l PANELS
Liesnx Clan_ LLCM -( =j
DateIZY 93MOritletor TYPED Ahes
RCHITEC`PS DECLARATION 201-1000AMPS
q�q�uu
Ob I understand my plana shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT.
hi Licensed Professional SIGNSELECTRICAL
<t OWNER-BUILDER DECLARATION
res SPECIALCE{CUfT/MISC
71.., (hereby affirm that l am exempt fromlhe Contractor's License Law forthe
O H following reason.(Section 7071.5,Business and Professions Code;Any city or TEMP.MLTTR OR POLE(NST.
K� countywhichmquimsapermlttomwtmoalter,Improve,demohsh,orrepalr
< anystmetumpdortoitsiauance,alsorequireatheappUmntforsuchpermitm POWER DEVICES
ry1 V filo a signed statement that he is licensed pursuant to the provisions of the
Ow Contractors License Law(Chapter9(mmmencingwith Section 7000)ofDIW-
30�^ slon3ofthe Buaineasand PmfembwCods)orthat he B exempt therefromand SWIM NG POOL ELECTRIC VALUATION
S°S the hams for the alleged exemption. Any violation of Section 7071.5 by any OUT"
TS 7CFiESF1%'I'11RE5 T r', ,I
0¢� applicant fora permit subjects n
the applicant to a civil penalty of not erethan
$ five hundred dollars($SM. NEW ESID AL ELECTR_SQFT. TORIES TYPECONSfRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the smoc ure is not Intended or offered for
sale(Sec.7044,Busmes suss Profeesimu CTh
ode: e Cantradce.LlcerueLaw
$ does not apply to an oweerof property who Wilds or improveon
Improvers there .and Dtu� m C.GROLID RES.UNHS
who doessuch workhlmsell or through hie own employees,provided that mets
improvementsare not lntendedoroficed for sale.If,howeveq thebuildingoTOTAL)
improvomentisaoldwithinoneyearofcomp101onthe owner-builderwlll have
OW-turden of proving that he did nut buOd or Improve for purpose of tile.). QTy. PLUMBING PERMIT FEE MNr
LJ I,as mucor the Property,am exclusively msitrul ng with me Codd PERMIT ISSUANCE 'l
contractor to construct Lidothe project(Sec.net apply
Business and of prop rt Code: 2
The Coor imprb License Law don not apply tct an owner of Property who ALTER-DRAIN A VENT-WATTS{(EA)
builds or improves thereon, and who coarcts for each plojMe with a
off, am
underpursuant.mthe Contractor's License Law. BACK FLOW PROTECT.DEVICE F1- SUMMARY
LJI am exempt under Sec. B k P C for this reason1-u�Tul eve
Owner— DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEPf at
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to self-InsureFIXNRF.S PER TRAP SCHOOL TAX Y N
,or RECEIPT g
mrtifioteofWorkers'Comperu mlruuranceoracedlfledropythereefoot.
380,Lab C.) GAS -11NC.4OUTLETS PARK FEE Y N
�a
Policy p (
RECEIPT If
Com ny GAS OVER4(EA) BUILDING DIVISION FEES
At copy fi reby Tum eh
Certifiea d ropy V filed with the c ty inspection division. S .GR DU STE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF E(EMPTION FROM WORKERS' G E PAID
COMPENSATION INSURANCE S AR -STORM EA.200FT. Date RCS( [B
Trhtssectien need not becomplated tithe permit Is forces hu dollars
L510(>orlesa.) AT . .1.�W,/VENT/a.rcTR ENERGYFEE Y N_
I certlfythat inthepcAomunaofthework forwhichthb pe t Is
I shall not employ any person In any manner so as to become m WA SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
-
zZ Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei tit
Z 0 NOTICE TO APPLICANT.H,after making thisCertificate of Exem Ion,you
I" should become subject to the Workers'Compensation provisions of he Labor � BUILDING FEE TOTAL:
CC N Code,you rust forthwith comply with such provislam or this permit shall be K6t f1 N'--'
W j dMmed revoked.
CONSTRUCTt thisa ons LENDING AGENCY SEISMIC FE
a (] ]herebyaffimkMft which t Lsacomtmction lending agency perform ELECTRIC FEE
� Z arm of Lender.Nwork(or which this permit is issued(Sec.3097,Civ.C.) TOTAL
LL O ender'c Name rl PLUMBING FEE
LL F (.enders Addreas %� OEEZ� QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythall have�applicatlonand statethattheabove lnformitiw
a is memo.Idgmeto comply with all city and county ordinances and nate laws PERMTTISSUANCE FEES PAID:
} relatingtobuildingmcstmction,and hereby authodu representatives oftht,
F city to enter upon the above-mentioned ve- tioned propertyInspection for Inspection purposes. ALTERORADDTOMECH.
Z Date ReCCI [N
_ (We)agree to save,Indemnify an d keep harmless;the City of Cupertino
against liabilities,judgments,costs and expenses which may In anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
against said City In consequence of the granting of this permit AIR HANDLING UNIT(OVER I QOOO CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS Of SCLOSURE
Will the applicant or future building oau pant store or handle hazardous HEATING UNIT(TO I MD,OW BTU) Date Recei tri
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the -
Ilealthand Solely Cod s Ion 25532(a)I HEATING UNIT(OVER 100,000 BTU) L.❑Yes o
Will the applicant rfuture building pant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUA TE
which credit hazardous air mntamW"ts as defined by the Bay Area Air ��� sI �
Qu alit Management Dist 7 BOILER-COMP OI@OR 100,000 BTU) 'JJ
Yes IJJ
I have read the haza ouematerLds requlmments under Chapter 6.95 of BOILER-COMP(OVER l 00,000 BTU)
the California I Iealth A Safety Code,Sections 75505,25533 and 25534. 1 �Ia
understandthatifthebuildingdoosnotarrentlyhaveatena"L that itismy NEW RESIDENTIAL MECH. 5Q.Fr •Ya of cane -
respmandit to notify the occupant of the requirements which mustbe met
Tutor to t r fOmpanry. SIN
' tyiylror jffth fi�dagont Date �}
TOTAL: ISSUED BY.. n.aY1"w-vy
OFFICE COPY