21781 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuIhNng Project Identification PERMIT NO. 1 7 81
Building Address:
el 3 ad
nera one•. XPM7FI1=BMH7ALDAIT
AGJ� A)aces _ CITY OF CUPERTINO-BUILDING DIVISION
• Contra r'sName: ,LIc.N. APPLICATION /PERMIT �a ✓�'9� -
BUILDINGELECnUCALPLUMBING-MECHANICAL CATEGORY CONTROL,#
Arc mrd/Engineer: Lm.No: BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address,goA 2. j2, PERMITISSUANCE 1:1 1:1 ❑ ❑
LICENSED CONTRACTOR'S DEC +TION
I hereby affirmthat l am licensed under provisions of Chapter 9(mmmen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwilh Sc on7000of DtWstm3ofthe Businesand PmfssionsCode,and myLs��
license Clit(ulI(o rad effect t PANELS
Lirens Classd :91 Lic. ryl3 VJ ,
Date Contractor a UP 2DO ANTS
70 AMPS
p�+0O Iunderstand my pARCHITECTS DECLARATION lans shall he used spubBcredrda. OVER 1000 AMT'S' SQ.FT.FLOOR AREA 5/SQ.FT.
FGI Licensl Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
p, 4 Ih...byafRrmthat l am exemptfromthe Contractor's License Law for the
ZO ,. following reason.(Section 70113,Business and Professions Code:Any city or TEsfP,METER ORPOLE INST.
FE countywhich requires a permit romrutrucL alter,improve,demolish,ormpalr
006 any structure prior to its issuance,also requires the applicant for such permit to POWER DEVICES
file"a signed statement that he is licensed pursuant to the provisions of the
3µ,y Contractor's Llceme Law(Chapter 9(mmmendagwlth Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
OJ gon3 of the Bukeessand ProfesioneCode)orthat he is exempktherefromand
o the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS—SWITCHES-FIXTURES
applicant far a permit subject the applicant to a civil penalty of net morethan
five hundred dollars(g5DO.
'4..' ❑I,as owner of the property,or my employees with wages as their sole NEW RESID121MAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure is net Intended or offered for
O sale(Sec.7046,Business and Professions Code:The Contractor's Llceme Law
$ does not apply to an owner of property who builds or Improves thereon,and
who doessuchworkhimselforthrough hisownemployees,provided thatsuch OCC.GROUP RES.UNITS
improvements are not Intended creamed for sale.IS however,thebullding or TOTAL:
improvementlssoldwithinoneyearofcompldbn,theownervbu0derwlli have
0W.Ifurden of proving that he did not build or improve for purpose of sok.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
u 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to remitted the project(See.7044,Business and Profemlow Code: ,QQ -
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojeds with a R FEE SUMMARY
},IlB�factor(,)Bernard pursuant to the Contradore License Law.
c LJ I am exempt under Sem B&P C for this reason BACK p(pW PROTECT.DEVICE
OUTSIDE FEES
Owner Data DRAINS-FLOOR,ROOF,AREA,COND. SANITARY RECEIPT p
WORKMAN COMPENSATION DECLARATION - FIXN[ffSI'ER IRAI' SCHOOL TAX Y N_
MI hereby affirm that I have a rertNcate of consent to"If-insure,ora RECEIPT p
mdlflcateofWorkers'Compematimlm mneemamrtifiedwpythereofCSec. CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT N
CByX.L.
Pallryp ^ _�hN-DO3 DO.3 GAS PA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
C. a
Certified copy is hereby hthcity
e city Inspection division.
furnished.
Certified ropy k Ned with the GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SCORN EA 200FT Date Recei t#
(Thi..edion need nat be completed lithe permit lsforone hundred d.ilara
(S10(fiorles.) WATER HEATER W/VFNf/E.ECTR ENERGYFEE Y_ N_
I certify that in the performance of thework forwhlchthis permit is Issued, .Qo
I.hall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
'O Z Applicant NEW RESDENTIALPLMB. SQFT. Date Recei t#
Z O NOTICETO APPLICANT.If,after makingthls Certlfcamof Exemptlon,you -
Fshould become subject to the Workeri Compemation prodait ofthe Labor TOTAL:
X N Code,you met forthwith comply with such provisions or this permit shall be BUILDING FEE
W 7 deemed revoked.
t1 CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyaoMfor tthem lsaromtmction lending ,Clv.Cj perform TOTAL: ELECTRIC FEB
M Z Lamdce Name forwhich this permit issued S .3097,Clv.CJ .00
U O Landele Name PLUMBING FEE
LL F- Lendce.Addm.. QTY. : MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certify that l have mad this application and state that the above formation
1 l.cormot.I agreeto comply with all city and county ordinances and Yate laws PERMIT ISSUANCE FEES,PAID:
} N relating to building construction,and hereby authorize representatives ofthis - -
it to entero n the alwvcmentloned for Inspection a ALTER OR ADD TO MECH.
F-
city
agree to save,Indemnify an d lamp harmless te Clryo purposes.
uFortbw Date .Receipt#
L) against liabilities,judgments,demand expenses which may in anywayamrue AIR HANDLING UNIT CrO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit. AICONSTRUCTION TAX
�a ^ 2 —. " / R HANDLING UNIT(OVER l0,000CFMJ
Sig nature off Applica /Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WBithe applicant orfuture Wilding occupantstore or handle hazardous HEATING UNIT(TO 100,000 BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: A/'00
❑Yes M No
Will the applicant orfuWm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I*IJeDATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Distdd7 BOILER-COMP UHPOR 100,000 8TLA
q Yea No MAR a z 1991
havereadthe hazar ousmaterialsrequimm ntunder Chapter6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Section.75505,25533 and 75534.I a�
understand that if the Wilding does not comently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. �
responsibilitytoofnotifyCertificate
of ccupanof the equlremenlswhich must be and WI�1 lwne'•..., l/�+ '
prior to issuance ofaCertiRmte o(Ompanry.
�°�' n a..1 Wit-acs a I Q
Owner or authorized agent Date TOTAL ISSUEDBY:
OFFICE COPY