19928 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Proed Identification - PERMTNO.
eanafing rca,: 1 19928
none:
WN'Il�lo'� CITY OF CUPERTINO-BUILDING DIVISION
Contractor'sName- Lie Na APPLICATION 1 PERMIT
Architect En r. BUILDINGELECTRICAI PLUMBING.MECHAM �
CAL CATEGCIRY CONTROLNJ
Lic. ce
zt� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreu: W� �� s PERMITISSUANCE El 1:11 , 1:1
❑ ❑
LICENSED CONTRACTOR'S DECLARATIO
I herebyaBlran that l am licensed under provisions of Chapter 9(mmmenc APPILANCFSRESIDENTIAL ]OB DESCRIPTION
ingwith Sec 7000)of Divhlen3oflhe BuWi and ProfesslonsCode,and my
license ll force and effect. PANELS
License Cle.Clam Contractor
ont Cont
Data ractor W ,
ARCHITECPS DECLARATION 301-IODO AMPS
NO O I understand my plans shall be used as public records. OVER 1 O00 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
LL�j kk�I OWNER-BUILDER DECLARATION
j'n a SPECIAL CIRCUIT/M15C
I hereby affirm that I am exempt fromthe Contractor's Liaame Law forthe
oo following reeon.(Seaton 70315,Business and Prons fessioCode:An cityor
FZ^� county which requires,a permit in ronstrua,alter,Improv,demolish,or reair TFMP. MEfEROR POLE INST. '
aeystructurs priorto Its issuance,also requlrestheappllcant for such permit to POWER DEVICES
C O file a signed statement that he Is licensed pursuant to the provLsiomu of the
EOO w Contractor's License Law(Chapter 9(mmmendng with Section 7000)of Divi- VALUATION
g elon3o(theBueincesand laraesslouCade)orthat hchcxemptthercfromand SWIMMING POOL FIECTRI
6 the bash for the alleged exemption. Any violation of Section 70335 by any OUTLETSSWIicHFSFD(TORESOr�'7
appllcant fora permit subjects the applkant to a civil penahy of not..the. S'00i o0
E. five hundred dollars($SM.
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTRSQ STORIES TYPECONSTRUCTION
p perry,or my employee with wages r ffer sole
m1.IS..70K
usinessl do work and lose sad.: Is not Intended orofferedfor
O sale IS..apply
to Business and Imfesef property
Cade:The Contractors License law
does not 5� whodes .uch torn owner o(p rough whobuilds
emplyces,povidedharem,thatand such — OCC.GROUP RES.UNITS
EEE whodoemnts amwork tintenedDraagh his own e.If,hoeverthebuildigor
Impmvementaarcnollntenomyearofcomroffiered orsak.them evbuilderi iln ve TOTAL:
ImprovemenHewldwllhln oneycarofcompietlon,lhcowner-bulMerw111��ve
t n9en of proving that hedidnabu0dorpmvefmpurposeefule.). QTY. PLUMBING PERMIT FEE
� bnFLOOD ZONE A]'N1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profession Code: E
The Contractors License Law does not apply to an owner of property who -
Wilds or Improve then em,and who contacts for such pAe)ects with a ALTER-DRAIN A VENT-WATER(EA)
ryD3T+ctor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this mason BACKFLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT It
WORKMAN COMPENSATION DECLARATION pIXgppR TRAP - SCHOOL TAX _Y_ N_
E]1 hereby affirm that I have a ceniflcate of consent to sell-marc,ors RFLIIDPI'N
certificate of Worken'CompereeHonfeurance or a certified copy themeof(Sec. GAS PA. WC.40UTLEIS PARKFEE Y N-
3800,lab C.) N—
Policy N RECEPT N
GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FF.ES
rtlfied copy is herebydwith the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
enNed copy h filed with the city Wpecilon dlvlelon.
CERTIFICATE OF EXEMFIrION FROM WORKERS' GREASE TRAP PAID ���t
3 2h9D
COMPENSATION INSURANCE SEWF.R-SANITARY-SIDRM EA 200FT Date Recti t# I I
(Thlssealon need not be completed lithe permit Isforove hundred dollars s
(Sl IO)orfyth) WATER HEATER W/VENT/ELFLTR ENERGYFEE Y N '
Illnot thatin othe person
of thework for s tobthis gemmule booed,
I shall r a employ any perwe In any manner w u to become subject to the
Worken'Compenutlon lawn of California.Dace WATER SYSTEM/TREATING PAID 3'2-I'qO �3
0 Z Applicant - NEW RESIDENTIAL PLMB. �.FT. .Date Recei t#
Z O NOTICE come subject
H,after rs deg Compensation
Certificateprovisions
Exemption,you
Code,shoulou=aaurthwit co Workers'Comprovisins orthimuofthe Lab be TOTAL:
N Code,you=at forthwith comply with such proWs,bu orthh permitshall be 72
� > rimmed revoked. � s
WCONSTRUCTION LENDING AGENCY SEISMIC FE e}
Ll I hereby af0rm that there h a conlructim lending agency for the perfarm- ELECTRIC FEE
Z anmaftheworkforwhichthbperMt Lslevmd(ec.3097,CIv.C.) TOTAL:
V O Lmders Name PLUMBING FEE
W f LenderLAddreu QTY. MECHANICAL:PERMIT FEE ECHANICAL FEE
OW incoI cenlfythat l have read this application and statethattheaboveleformatlan M
a rrect.l agreeto complywlth all city and county ordinance and state laws PERMIT ISSUANCE FEES PAID:
>. N relating tobullding coratmction,and hambyauthonee representallvesofthh
f. Z city toenteruponthe above-mentioned property for Inspection purposes. ALTERORADDTDMECH. Date ReCel IN
L..I (We)agree indemnify to save,indeify an d keep harms,lethe City of Cupertino
ago WtllabNtlee,jadgmenh,rash end expenses which may in an wayeecrue AIR HANDLING(IMT CFO 10,000 CFM) SUBTOTAL:
'agalut old City In nsequ ao(the anting athb c
AIR HANDLING UNIT(OVER IO,000cm CONSTRUCTION TAX
Sigmlurea pplicant Contnaor _ Date F7(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant stere or handle hazardous HEATING UNIT(M I0D,0D0 BTU) Date Recel tN
material m defined by the C.pent.Municipal Code,Chapter 9.13,and the
Ilea lth and Safety Coda Section 75533(a)7 HEATING UNIT(OVER 100,OOD BTU) TOTAL:
❑ Yea No
WW the appllum Mrs building occupant use equipment or devices VE ELATION FAN(SINGLE RFSID) ISSUA
which enit haeardom air contaminants as defined by the Bay Area Air.. BOILER-COMP pFI'DR l00,IXq BTU)
Quality Management District?
Wu4hYvo ❑aNo o
.- t ti, A
ILrR-ODMP(OVER 100,DDO BTU)
ereadthebazarcousm
theCifcmhHealth&SfetyCd,Sctiou25MS,25533and75534.
I 1t .{
understand that lithe building does net currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. City of Cunerhno
rmpomibility to notify the occupant of the requirements,which must be nM _
prior to Issuance of a Certificate o(Occupanry. ,
Owner or authorized agent Date -TOTAL: ISSUEDBY: a
OFFICE COPY