20464 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bulldleg Address: '/0 A 6 4
10270 G !}
wnero area: one: -
Hung Lai ;),q9—AliCITY OF CUPERTINO-BUILDING DIVISION A C,
Contratar.N.ene: Lie.No: APPLICATION /PERMIT �l•O
'
F BUILDING-FlMMCALPLUMBING-MECHAMCAL CATFLORY CONTROL#
Architect/Engineer. ic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ® E]LICENSED CONTRACTOR'S DECLARATION IX
I hereby affirm that l am licensed under provisions of Chapter 9(eommrn APPLIANCFSRESIDEMTAL JOB DESCRTPDON
IngwitleSeMon 7000)of Dlvbion3ofthe BuMnemandProfnsionsCode,and my
bcenx I.in fel tone and effect. PANES ,remodel bath rooms
License Clam `j -;36LICX�' dfl 7_$'3 _ '
Date Contr oI �'�
A ' Plumbi 701-10DOAMPS _PI nmhi n—/rcni
ARCHTfix, lunderstandmy plays ahaRbe used as publicrecorde. OVER 1000 AMI' SQ.
Licensed Professional SIGNS ELECTRICAL
4 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MIST
f.,�4 IfurmbyaffinothatI am exempt from the Contractor's License Law for the
0 po~ following reason.(Section 7031S,Business and Pretensions Cade:Any city or
�z � countywhichrequU aper twcowmct,alter,impmwdemolbh,orrepair TEMP METER OR POLE INST,
ystm=mpdortolts Wuame,alsorequU stheapplicantfmsuchpermitla POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
Owl Contractor's License Law(Chapter 9(rommencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
30 Ion of the Business and Profeeslans Cods)orthat he b exempttherefromand VALUATION
Gthe basis for the alleged exemption. Any violation of Brettn 7MIS by any OUTLETSSWITCHESFIXfURFS
O applicant for a permit subjetstheapplicant to a civil penalty of not nnre than
five hundred dollars($50%. NEW RESIDENTIAL ELECTRSQ.Fr. STORIES TYPE CONSTRUCTION
o ❑i,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure is not Intended or offered for
O sale(Sec:7044,Beat..and Profession Code:The Contractor's License Law I
3$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES UNITS
who doessuchworklemselorthrough hisownemployees,provided thatsuch
Improvements are not Intended oroffered forsale.If,however,thebulldlegor TOTAL:
mprovemoutaSokiwithlnomyearofcwnpldbntheowner-buRderwill have
tlle);urden of proving that he did net build or improve for purpose visile.). QTY, PLUMBING PERMIT FEE FLOOD—ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to ronstruct the project(Sec.7044,Business and Pedesslans Code:
The Contractor'.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such projects with a FEE SUMMARY
.d.r(s) somas, punouittotha ConmictorsLkense Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sea B &P C for this reasonOUTSIDE RES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY -- Y_ N
� Owner Date RECEIPT 0
i WORKMANCOMPENSATIONDECLARATION FIXTURES PER TRAP SCHOOLTAX Y N_
❑I hereby affirm that I have a certificate of consent to self-Inure,car a RECEIPT X
certificate ofWorkeri Compensation Insurance car a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFFE. Y N
3800,lab C.) RECEIPTp
Policy# GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
�CertRled copy is hereby fumishrd. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE .
Certified copy In tiled with the city inspection division.
CERTIFICATE OFEXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEV.'F.R- STORM-S10RM EA 700Fr. Date Recei t#
(This section need not be completed if the permit b forom hundred dollars
(8100)mlenJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of the work for which this permit Is hosued,
I shall nm employ any person in any manner so as to become subject to the WATER BYETEM/TREATING PAID
Worker'Compensation lawsof CaR(orNa.Date
OZ Applicant NEW RES DENT AL PLMB. QF. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
(�) Cade,you must forthwith comply with such peovisioru orthis permit shall be _ ING FEE
W 9 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L Ihereby affirm that them le a construction lendlegagency,for the perform- TOTAL: ELECTRICFEE
M Z ante ofthe work forwhich this permit is Issued(Ser.3097,Co.CJ
1.) O Lender'shame PLUMBING FEE -14.00
IL F Lender's Adder. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertilythatlhaveread this apploutionand tatethattheabovelnformation
IL bcorrect.I agree to comply with all city and county ordinances and state law. PERMIT ISSUANCE FEES PAID:
�. W relating to building construction,and hereby authodze representatives of this
H Z city to enter upon the above-mentioned property for inspection purperia. ALTER OR ADDTO MECH. Date Receipt#
(We)agree to save,indemnify an d keep hammier the Cityof Cupedlno
V agalnd hablBde.,Odgmentq cosnand expense.whlchmeymanywayamue AIR HANDLING UNIT O'010,ODO CFM) SUBTOTAL:
against Bald City In con ence of the grantin f tNs permit
X� �= p AIR HANDLING UNIT(OVER tO,WOCFM) CONSTRUCTION TAX
i 9 64 CONSTRUCTION TAX PAID:
SigmtoerdApp cant/ .Mrsem, a EXHAUST HOOD(W/DIKT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BTTI) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the I y
Health and Safety Code Section 25531(a)7 HEATING UNIT(OVER 100,000 BTTJ) TOTAL: '
❑Yee tU No
Will theapplloant or(utum buildingoccvpant use equipment or device. VFNTILA11ON FAN(SINGLE RESID) FMPE.E DATE
which emit hazardous air contamimnts as deflead bythe Bay Area Air 1
ity
nt
atrict? BOILER-COMP
OR 100,00i)BTU)
I Years.d the lruDarrcro smaterials requirements antler Chapter 6,95 of BOILER-COMP O}VIA 100,0000TU) n` G(` J `990 '
' the Olifomia Health&Safety Code,Sections 75505,75533 and 75534.1 PIU U
understand that if the building due.not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FL rI}4, ss{�a, .k,
responsibility to notify the occupant of the requirements which must be ret CRY Uf. 4lflnpellnQ
priori ixauanceofa rtlfk,ur.f0ttu to
�t f-Y
Owner or a�hv zed agent Date ISSUED BY:
TOTAL:
OFFICE COPY