20565 APPLICANT TO FILL IN INFORMATION WITHIN.RED LINES --USE BALL POINT PEN ONLY-
Building Project Identification PERMIT NO,
Building Add rem: N�O C JC
/0�.0/ d 20 i},Q G J
wnere a one:
PPL CITY OF CUPERTINOBUILDING DIVISION
i . COnrader' Name: .t1 Lk,Nee APPLICATION I PERMIT (O l
L 7 V61.7 BUILDING-ELECnUCALePLUMBINGMDCHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - qq
LICENSED CONTRACTPFRh9TI%UANCE CONTRACTOR'S DECLARATION �`•O1:1 El
I hereby affirm that l am lkensed under provisions of Chapter 9(commeno APPLIANCESRERDENTIAL JOB DFSCRR'IIUN
Ingwith Sedton7000)of DiNsion3ofthe Businmand Pmfe msCode,and my
PANELS
LF le In fu0 or¢uuyydd dfM. a�
Dale Conlndor_ ✓ //.TI Ea'E�' 7UP 0 200 AMPS
ARCHITECTS DECLARATION
q�u M:, l understand my plans shall Ear used as public records. OVER1000AMPS SQ.F[.F7.00R AREA $/SQ.Fr.
f4LI¢nsed Professional SIGNS ELECTRICAL
< OWNER-BUILDER DECLARATION SPECIALCIRCIAT/MLSC
F, 1herebyaffivnthal l amexempl from the Contrador's License Lw for the
62 following reason.(Sed1on7031S,Buslnenand Profmlons Code:Mycityor TEMP.MEfIXORPOLE INST.
F� cauntywhlchrequimapem*mmmerud,ilter,Imprw demoWh,orrepalr -
anystructurepikertoltslssuance,alsomrylrnlheappllcant forsuch permit to POyyERDEVICFS
file a signed statement that he is B¢'med pursuant to the providers of the
3 w Contractor's License Law(Chapter 9(corrmancing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
bi slon3 of the Budomand Pro(mlom Code)orthat he b exempt therefromand VALUATION
the Web for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESHXTURES
4 applicant for a permit subjects the applicant to a civil Penally of not more than
five hundred dollen MM. NEW RESIDENTIAL ELECTR
[:]1,as owner of the property,or my employees with wages as their sole �'FT' STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is not Intended or offered for
O
.to(Sec 7061,Business sad Profmlom Cud,:The Conlredor's Lt..Law
$ don not apply to an owner of property who builds or Improves thereon,and OCC.GROIIP RES.UNITS
E� who docs uchwork himself orthrough his own employees,provided that such �r O
improvements are not intended oroffered for sate.If,however,the building or - TOTAL:
Improvement 13sold within one yearofcomplelWn,the owner-W fiderwill have
the burden of proving that he did cart build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
mnlrectorf to mmlfud the project(Seo 7061,Ruslnm and Profmlom Code: PERMIT ISSUANCE
The Contractor's License Lw don not apply to an owner a property who
Wilds or Improves thereon,and who contracts for such projects with a ALM-DRAIN&VENT-WATER(FA)
am
or(oempt under
u¢nsed pursuant to the Contrado's License Law, FEE SUMMARY
d er Seo B k P C for Ihla mason BACK FLOW PROTECT.DEVICE
I
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Dee v RILEII'F N
WORK MAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑I hereby affirm that I have a cedlfkate of consent to self-inw¢,or• i� Ii RFCm•F N
unifimteofWorkers'Compemalionlmuranca¢amdifdmpythereof(Sec. GA5-EA. -IINC.IOUTLEIS '^ PARK FEE Y_ N
3800,Lab CJ — Fn —
RFGEIPT N
Comryan�vCL�s✓�- Ga> 1(` 'Z�73 GASEA. eIRM-OVER 4(FA)j I II i� B^ BUILDING DIVISION FEES
CertNed ropy b hereby lumlahed. GRFASE/INDUSTRL WAS1EI P CHECK FEE
CedNed ropy b flhd with the city Wpedlon division.
CERTIFICATE OF IXEMPFION FROM WORKERS' G r P ID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 7mFT Date Recei tN
(Thlssedion need not be completed if the permit is forone hundred dollars
(Stm WATER HEATER r'4/YEAR./EI.ECTR ENERGY FEE Y N
I¢dlfy ifyth shat lothe pedortmn¢of the w¢k forwMchtMs penmlt le laaued, - ,
I shall not employ any person In any manner to as to become subject to the WATER SYSTEM/TREATING
Worked Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDFIJ77N,PLMB. SQFt. Date Recei tq
Z O NOTICETO APPLICANT:If,after makingthb Certifesteof Exemption,you
should become•ubjed to the Workers'Compensation provisions of the Labor TOTAL:
f/7 Code,you must forthwith comply with such pmvbiom orlhb permR shall be
W > dnmed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby aflmr that the¢is a construction lending agency for the perfomm TOTAL: ELECTRIC FEE
7 Z ance of the work for which this permit is issued(See.30W,Civ.CJ
O O Indere Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ¢
Irtitylhat l have read this appliallonaad statethal lheaboveinformation
1 bcorred.l agree to comply with all cityand county ordinances and stalelaws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and herebyaulhorize representatives ofthb
I— Z cit)m enter upon the aWve�menllonM property for inspection purposes. ALTER OR ADD TO MFGH. Date Receipt# '
(We)agree to save,Indemnity and keep harmless the City of Npertino AIR HANDLING UNIT(TO 10,000 CFM)
V liabllides,jadgmenle stsande seswhk ma inanywayace,ue SUBTOTAL:
agalm said City in con of I ting of s
6 / AIR HANDLING UNIT(OVER I0,0D0CFM) CONSTRUCTION TAX
core of Applicant Conrado a EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIA DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT 100,000 BTU) Date Recei tq
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Ccx!EL dlon 75532(a)7 HEATING UNIT(OVER 100,000 BITJ) TOTAL:
qYn MN. VENTILATION FAN
ill the zpplianl or future building occupant use equipment or devices (SINGLE RESID) IgqgqUAN(;F,DATE'
which emit haeardous air costamBuns as defined by the Bay Area Air A��(„�I
• Quality Management Mind? BOILER-COMP OHP OR 10I BTU,
4 Yea r.o J U:11
haveread the hoz Lia mode,le tions 2rrenbunder Chapter 6.95 of BOILER-COMP(OVER]00,000 BTU) iyyU
the Callfomla Health b ildi.Code,SMlar,75505,765.73 and 7that i I
understand that if Ne bullding does not mrrently haveal nanq that It Is my NEW RESIDENTIAL MEIN. SQ.Fy .
res lity to notify the ocmpan therequircmenb hlc slbemet ^Ib!
orm ancepfaCertlfkae pa 4f Cupertino
nor authors agent Date - ISSIIEDB4.' L
TOTAL:
OFFICE COPY