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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Idemlicatlon ���a (,I-F,al{ '�"q
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PERMIT NO.
62_3. 19927
mars ansa: - hone:MUM
C_^bALLL J-t1NNA CJ/Ad
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
3 21 O
cmntrsdor'. Name:sae Neo
BUILDINGELECTRICAL-PLUMBINC-MECHANICAL
CATEGORY
CONTROL Y�Ji�
=J //
Arohltect n nee Llc. No:
QTY ELECFRICPERMIT FEE
BUILDING PERMIT INFO
Address:AjAtjO �
PE6,9TISSUANCE
LICENSED CONTRACTOR'S DEC TION
Ihereby afftrm that l am licensed under promkionsof Chapter9(conunenc'
Ing with Section 71)(0) of Division 3 ofthe Business and ProfessionsCode, and my
license is In tali faro and effect.
Cbss LIeY
APPUANCESRESIDENfIAL
JOB DESCRIPTION,
sss---
Ri•�n ��Cn ^ •�Pw%�
PANELS
'
Dense
Dale Contractor
201-1000 AMP"'
ARCHITECTS DECLARATION
I understand my pH ..hall be used as public records.
OVERIODOAMPS
SQ. Fr. FLOOR AREA
.$/SQ. Fr.
SIGNS ELECTRICAL
Licensed Professional
Q
SPECIAL CIRCUIT/MISC
DECIARATION
to
I hmebyaf mnthat I am exempt from Ue Contractor's License Law fa the
TEMP. METER OR POLE INST.
following mason. (Section 7031S, Business and Professions Code: Any city or
countywhich requires a permitwmmtrud, alter, improve, demolbh,orrepalr
any stwoom prior to its issuance, also requires the applicant fee such permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEIq CPA
SWIMNUNG L E
0O�'E � 1 W
Contrad.e. License Law (Chepter9(mmmench,S with Section 7000) of Divi-
sian3 ofthe Rusinm and Pmfmbm Code)orthat he b exempt therefmmand
the breis forthe aIle exem Ion. An violation of Section 7031.5 an
appllant for a permit subjects, the applicant to a civil penslty of nos morcthan
e dred dollus (5500).
v I, as mer of the property, or my employees with wages as their sole
m sation,willdothework;andtheatmmmisr ct Intended or offered forM
le (Sec. 7096, Buainsss eM Profmtom Code: The Contrector's Llama Law
VALUATION
1 O� -; �Ot
-J
NEW READ AL SQ.Fr.
STORIES
s�0
`••aa
TYPE CONSTRUCTION
[•'
f"
11
does not apply loan owearofproperty who bulld.mimprovm thereoryand
who doessuchwork himselforthrough hbownemployees, provided thatsuch
Improvementsarenotintendedoroffemdfaaale. ILhowever,thebulldingaTOTAL:
N
1
rhij
OCC.GROUIs
RES. UNITS
improvement issold withinoneyearofcamplelorytheawner-buRderwgI have
t"rden of proving that he did net bu0d or improve for purpose ofsale.).
Lj L as owner of the property, am exclusively contracting with licensed
rontracton to ronslmct the projM (Sec 7014, Bualnm and Professions Code:
The Contractor's License Gw doss rad apply loan owner of propertywho
Wilds or Improves thereon, and who contracts for such pRojecta with •
cgWractor(.) licensed pursuant to the Contractor's License Law..
LJ I am exempt under Bee B & P C for this reason
QTY. I PL IN ERMIT FEE
'FLOOD ZONE
APN
LTJ
P LSSD CE /e1 xco
1 �s
I
- WA
O.a
FEE SUMMARY
BA
.D EW
DRAINS RA
SANITARY Y_ N_
RECEIPT Y
Owner Date
WORKMAN COMPENSATION DECLARATION
❑1 hereby affirm that I have a certifiale of consent to self -insure, oraTFAP
certificate ofWorlha Compansadrs
onlmunce or a certified copythereot(Sec,
38W,Lab C.I
C is
SCI100L TAX Y_ N_
RECEfPTY
GAS EA. SYSTEM -1 4 U3LE15 Z�
PARK FEE Y N_
ftE EP'T Y
Cc
Cc
Com any -
GAS EA. SYSTPA4-OVER (EA)
BUILDING DIVISION FEES
copy is hereby furnished.
❑ Certified ropy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thi..acin ioneed nos be complded if the permit V m forahundred dollars
GREASE/WDUS[RL WA INTERCEPTOR
PLANCHECK FEE -
' f. `.-
` !M lam^4'f
PAID�^'a•Vw J�'y
Date Receipt OJ
GREASE TRAP
SEWER -SANITARY -STORM EA. 2l10P1.
WATER HEATER W/VENT/ELECTR 2�
ENERGY FEE Y N_
PAID 1�1 6�.
.•s �s
Date Recel t# 1 I sC0
($100) or lm.)
I artlfythat In the pedm
oanceof thewak forwhich this pemdt is Issued,
I shall net employ any person In any manner so as to become subject to the
Wmkers'CompenaaHon Lawsof California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should becomes subject to the Workera Compensation provbions of the Labor
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFf.
TOTAL:
BUILDING
Code, you =at fork hwith comply with such provlsinns or this perrrdt shall be
dead revoked.
coNsrftucrloN LENDING ACFNcr
-
SEISMIC PEE'1-7
Ihembyaf km that thea b a comtmdion lcndingagency forfie perform
ana of the work for which this permit is Issued (Sec. 3097, Clv. C.)
lender's Name
Lender'.Address
I certilythatl have read thlaapplialionand statcihallheabove information
is correct. I agreeto comply with allcity and county ordinances and state laws
TOTAL
tlz
ELECTRIC FEE Q
PLUMBING FEE .Q7
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE 'JZ
PERMITISSUANCE 2x�
FEES PAID:
relating tobullding construction, and hereby authorlu mpresentativesof thio
dtytoenterupon the above;rdentiorad property fee lropecion purposes.
(We) agree to save, N fmNfy a d keep harmim the City of Cupertino
against liabilities, ptlg rats, mdse dexpan. which may In an wayacaue
Date Recei t#
ALTERORADDTOMECH. Z4y
AIR HANDLING UNIT IO 10,000 CFM)
SUBTOTAL:
against said City in enao egranting olthla pe t.
AIR DANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
gnamreot puce omrsder Date JIt
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSUR
Will the applicant or futurebu0dingoavpantstore or handle havrdous
material as defined by the Cupertino Municipal Cade, Chapter9.IZ and the
ldealthand Safety Code Sodium 25532(a)2
❑ Yes ,l+�, No
Will the applicant cam, building occupant use equipment or devices
Date Recei t#
1 HEATING UNIT (70 100.010 BTU) DadD'
HEATING UNIT (OVER 100,001 BTU)
TOTAL: a
VENTILATION FAN (SINGLE RESID)
ISSI,[®+WATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
II Ihavereadthe bar QZoueomaterials requirements under Chapter 6.95of
JUN 2 v jyyJ
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
"
the California Health & Safety Code, Sections 25505, 25533 and 25534. I
understand that i(t bulld g does not currently have a tenant, that it B my
NEW RESIDENTIAL MECH. SQ+r.
responsibility to tythe pant oftherequirements is
pdortoissuan ofa Ce f to ofOav Panry.
��s�4.a
Yty, MYIaGY
City. /a„^'���
ISSUED BY: v�� i
morAra.11(oricadYgent Dat
TOTAL:
OFFICE COPY