23212Aaal ICANT TO FILL IN INFORMATION WITHIN RED LINES =- USE BALL POINT PEN ONLY -
Building Praia d Identification -
Building Address:
PERMITNO.
,
23212
as
nerd ams: - _ one:
-
„ A
' ' -
CITY OF CUPERTINO-BUILDING DIVISION,'
APPLICATION / PERMIT
BUILDINGELECTRiCAI.PLUMBRJG-MEC14ANICAL
emfra 'a Name: - r Li Na:
/ .a 7g
CATEGORY
CONTROL'#
Architect/Engineer. f- Lk. Na
OTT ELECTRIC PERMIT FEE
BUILDING' PERMIT INFO `
Address
PERMITISSUANCE '
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thatI srt licensed under provisions of Chapter 9(commmc-
ingwith Section 7000).Mb islon 3 ofthe Buslnessand Profession.Code, and my
license le In fu foL& .4 effect.
License Clam LtcN OZ S / ,f
D.W Contredor pUMVf�
APPLIANCESRESIDENTIAL
JOBDESCRIPTION- '
'
�.L
1. r + l
PANELS
201-1000 AMPS
I- as 90 ARCHITECTS DECLARATION UUV
• I understand my plans shall be used as public records.
OVER IODO AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL ..
Licensed Professional - ••
OWNER -BUILDER DECLARATION]"
Ihereby affirm that am exempt fromlhe Contractor's License Law for the
following .... (Sedion7031.5,BuslnessandProfessionsCode:Anydtyor
countywhich requiresa permittommtmd, alwr,lmpmw, de=lUh,orrepalr
L ED IN "
SPECIALCIRCIRT/MISC
7FMP,METFRORP0LEINST.
prlorto its l mancgai mquimstheappRcantforsuch permitto
file a signed statement that he b licensed pursuant to the provisions of the
POWER DEVICES M%p1
_
1
v
.
CERanystructure
ontractor'sLicense
Contractor's License lawmfewer9Cconurencing thathetemmptthemfof Divi-
r9 Code)arthat with Section
n7000fromarW
the basis for the alleged exemption. Any violation of Section 703LS by any
applicant for a permit mbjedstheapplicantto a civil penalty of net more than
SWIMMING BOOL ELECTRIC
OU7LETSSWIICHFSFI%7URES asasasssaV
CATION
A B� "
NEW RESIDENTIAL ELECTR Fr.
`'�
five hundredasowmalLn ($500). -
I, as owner of the properly, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compensation,willdothework, andthestructure is not intended or offered for
sale (Sec. 7014; Business and Profewsms Code: The Contradoes License Law
does not apply to an owner of property who Wilda or improves thereon, and
who does suchwork himselfwthrough Ma own employees, provided that such
- -.00C.
GROOP
RFS. UNITS {
improvements are net Intended or offered for sale. If, however, the building or
TOTAL:
-
improvement issold within one yearofeumpletam, the owner-builderwil)have
' ,
tlyLIIurden of provingthat he did not build or improve for purpose ofsale.).
u L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7014, Business and Professions Code:
dry. PLUMBING PERMIT" FEE
FLOODZONE
"
APN
PERMIT ISSUANCE I ,�
- `
The Cdntradorb License Law does not apply to an owner of property who
builds or Improve, thereon, end. who contracts for such plajeats with a
cgBj(actor(s) licensed pursuantto the Contractor's Licenss Law.
t51 am exempt under Sec B k P C for this reewn
ALTER -DRAIN & VEM-WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDEFEES -
DRAINS. FLOOR ROOF, AREA, COND. 4
SANITARY Y_ N_
RECEE'r N
Owner Date
r-�(, WORKMAN COMPENSATION DECLARATION
V' hereby. affirm that I have a adi(late of consent ro self -Insure, w a
cenifirste of W�orrka.' Compensati��otan l�nsurana.ra certified copy thereof eacc.
380Pol, Nb C.)L4 Ze l76o ocd^' I
W 'P
FI)('IVRF_S PER TRAP �
SCHOOL TAX Y_ N_ -
RECEIPT N
GAS EA. SYSTEM -1 [NC.40UTLECS
PARK FEE RECEB"C N
GAS FA. SYSTEM-OVER4(EA)
Cam any Mk L7 A/
_ �
BUILDING DIVISION FEES
ffCedlOed copy In hereby furnished. -
Certified copy Is filed with the city fimpedion division.
GRFZSE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
'
GREASE TRAP
CERTIFICATE OF EXEMPFION FROM WORKERS'
PAID.
COMPENSATION INSURANCE
( hissedion need net becompleted ifthe permit isforone hundred dollars
Date Recei t#
SLWF.R-gAM•1.ARY-510RM EA 100[x[•
�' WATER HEATER W/VENT/ELECTR'.
ENERGY FEE Y N
—
($100)wfythat in
]certify tmannerhework ich permit is issued,
employ an person inannce so as to
I shall not employ any person In any manner a es to berome subject to the
Workers Compensation laws of California, Date
PAID
,
WATER SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you,
should become subject to the Workers Compemrovision o(the L
atkm pabor
Date Recei tN
NEW RESIDENTIAL PLMII SQFT.
-
TOTAL:
FEE
Code, you must forthwith comply with such provisions or thio permit shall be
deemed revoked.
-
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-BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is a commuction lendingagency for the perform-
' ance of the work for which this permit is Issued (Sec. 3097, Civ.C.)
lander'. Name
Lead.e.Addmsa -
Imdifythatlhavemadthbappli tbnandatatethattheabovelnformatlan
isromset.Iagrea to comply with all city and county ordinance, and gate laws
q'.r
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAVPERMIT FEE
-
MECHANICAL FEE '
-
PERMIT ISSUANCE - -
FEES PAID:
,
relating'tobulldingcorutructim, and hereby authorize representatives ofthis
citytoenterupontheabove-mentioned property for inspection purposes.
Me) agree to save, Inde ify an d keep harmless the City of Cupertino
agaWtBabllitle�7a menti, sesandexpenseswhich yin, ywayaccrue
- -
ALTER OR ADD TO MUCH. -
.Date Receipt#
-
AIR HANDLING UNIT (x010,000 CFM)
SUBTOTAL:
ago t eai City I oneequ tM gr' of tN, ertnit
„
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
si nn reo A urant/Contr or ata
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAXPAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO .I00,ODO BTU)
Date' Recei to
Wlllthe applicant orfuture building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
Health and Safety Cade section 25532(a)7'
Yea f No -
. Will the applicant or future building occupant use equipment or devices,
HEA TING UNIT (OVER 1f ,"BTU)
., TOTAL:
VENTILATION FAN (SINGLE RESID)
- ISSUANCE DATF�
which emit hazardous air centamlmnb as defined by the Bay Area Air -
Quality Management District?
4Y'. n No
have read the haze ous materials requirements underChapter6,95 of
Ii1
„ Ir 7a1
q
BOILER-COMPDHPOR100,000BTU)
ROLLER-COMP(OVER 100,000 BTU)'+.
the California Health A Safety Code, Sections 25505,25533 and 25534. 1
'r BRN a 199EJL
NEW RISIDENTIALMECH. SQ.FT.
understand that lithe building does not currently have a tenant, that It le my
f1
rriorto isms cent ify aCereocvpantof panty.he iremenls which must be met
prior to Lssuanre of d Certlfkate of Occupancy.
AnL�'DEDBY:�1
Owner or authorized agent Data
TOTAL:
OFFICE COPY