19919 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro ed Identification PFRMITNO.
BnBv `02 Q S 19919
nen ams: Phone:
S UC 'HAN X JN CITY OF CUPERTINO-BUILDING DIVISION
�" Lic.//No; : APPLICATION I PERMIT G
"ASON(E ��) is BUILDING-PLECTRICAL-PLUMBINC-MECHAMCAL CATEGORY CONTROLp
Architect/Engineer. Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addma: 14MTISSUANCE 1:1 ❑ 11LICENSED CONTRACTOR'S DECLARATION
I hereby mfbm that l am licensed under provWons Ol Chapter 9(mmmena IP
APPUANCESRESIDENTIAL JOB DESCRIPTION
Ingwith5 dbn7D00)of Dlvigm3ofthe Buaimmand P.feselonsCade,andm
lire..ismfu1fO dfect. C PANELS / �a.Y �/ Y—�91�
Llcen.GWeeC-YL_a Lic.Y�i E�SiDN (i 41 /NF. Ji f KCF9 ✓!p,
Date L^.TI—C4�ConlnRorUp To2DOANTS
ARCHITECT' DEC KATION 201-IODOAM
a0 2❑ I undenland my plana shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $M.FT.
E (D Licensed Professional SIGNSELECTRICAL
<< FkFkd�do
OWN
ER•RUILDER DECLARATION grp-CIpL CIRCUIT/MISC
1herebyaffirm that[am exempt from the Contractor's License Law for the
pp "-"greason.Cketion 70115,Business and Profession.Code:An or
O F+ (°BoTEMP METER OR POLE INST.
P� cwntywhlch requlresa permit[.corW
uct,mm
Idler, deolbh,o city rrepair
a. anystrocture priartolts bauance,also requires theapplicentfor such pematto POWER DEVICES
n Ilea eigncd statement that he is licensed pursuant to the provisions Of the
O w Contra e$Licerue Law(Chapter 9(commencing wkh Section 7000)of Divi-30� VALUATION
^ sion3ofthe Busand Professions Code)orthat hebe.mpt therefromand SWIMMING FOOL ELECTRIC
Ness
O S the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETS SWITCHESFIXTURES 1 D8
LEG45]1
applicant fora permit subjedsthe applicant to a civil penalty of net more than IG
$ five hundred dollars($500.
�n ❑I,as owner of the roe NEW RFSIDENi]ALELFLTRSQ.FT. STO TYPE CONSTRUCTION
property,1,a or my employees with wages r their door
compensation,7044,Business
doth.workaessimabudureh cotIntended orofferedfor
O sale(Sec.7046,Bueb�ess and Professions Codd:The Contnctole License Law
$ does not apply to an owner of property who builds or improves thereon,and OCC GROUP RIS.UNITS
who duce suchwarkhmn elorthrough Msownemployees,provided that such
Improvements arena intended metered forsale.If,however,thebuilding or AL:
improvement beold withinoneyearofcomplet Wgtheowner-bu0derwlli have
t e rden of proving that he did eat build or improve for purpose ofsale.)' F100DZONE APN
Q PL B MI FEE
Lj 4 as owner of the property,am exclusively contracting with licensed PERMI'TISSUA
contractors to corutruct the project(Sec.7006,Business and Professions Cade: '
The Contractor.License law does not apply to an owner a property who pL -D A
Wild.or improves thereon, and who contracts,for such pieJects with a FEE SUMMARY
cgBlE�doge)licensed pursuant to the Contndora License Law. A FLOWER T.DEVIL
LJ I am exempt under See B&P C for this reason
DRAIN OSANITARY Y Ed
• OUTSI Dr.FEE S
Owner Date DF,A RECEIPT
Kp
WORMAN COMPENSATION DECLARATION SCHOOLTAX Y_ N_
❑I hereby affirm that 1 have o legume of consent to copy
there. ora RpOEgs.T p
certificate o(Worken'Compenutlon Wurance ora certified mpytheneof(Sec. AS -1 60 EIS PARK FEE Y N
En G J
Pollry RECEIPT p
Com ray /dna/ A 1 GAS' V6 ) BUILDING DIVISION FEES
IZ C.
p le the
city
division.
GREAs / USTRI.w - TNTERCErroR PLANCHECK FEE -
Certified copy b filed with the city Inspection dlvimon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEWER-SAM.T•ARY-51ORM EA.pBFI• Date Recef [#
TTM.eection need not be completed if the permit b forone hundred dollar
(4100nrWATER HEATER W/VENT•/ELF.CTR ENERGY FEE Y N
I certify
th that N the performance.(the work(orwhkh this permit is issued,
10.11 not employ any person many manner so asto becoma subject to the WATER SYSCCM/TREATING
Worla,a'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PIMB. SQFf. Daft Recei f#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
Fshould become mbect to the Workers'Compensation provisions of the Labor TOTAL:
LOCode,you rwatfull hwith comply with such provisions or this permit shall be BU
ILDINCTEE
W > deemed revoked.
WG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hembymfirmthat there is a comtmctlon lending agency for the perform TOTAL. ELECTRIC FEE
a
D O sore of the work for which this permit is iend(Sm 3097,Civ.C.)
lender'.Name PLUMBING FEE
LL 1- Lcnd.r.Addrea. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O,W lcdifythatlhavereadthbappBationandgatethatthe aboveinformation
1 bcorrect.I agreeto comply with al dtyand county ordinances and gate laws PFRMRLSSUANCE FEES PAID:
} relatingto Wilding construction,and herebyautheriee repreemativesolthis
F W cRy[.enterupon theab.vnm.rui.ned property for Inspection Purposes. ALTER OR ADD'TO MECH.
Z (We)agree to was,Indemnify an a keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,mgsand expeneeswhkh maylnanywayaccme AIR HANDLING UNIT(TO 10'"CFM) SUBTOTAL:
agaasald icy in cgn.aryenm of the graining dthi.permit. AIRHANDWNG UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Signature of Applicartt/Contractor--f Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous HEATING UNIT(TO 100,0DO BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code ion 755ffiG)7 HEATING UMT(OVER 100,000 BTII TOTAL:
11—�11 Yee We
�1'0l the appliant. rebuilding occupant use equipment ordevices VENTILATION FAN(SINGLE BIRD) ISSUANCE DATE
which coot harardous air contaminants as defined by the Bay Area Air
• Quality Management t 7 11011ELCOMPOH[POR 100,000 BTU) 44 N
4Yea o
havereadthe haca .usmaterialerequirementsunderChapter6.95of BOILER-COMP(OVER 100,000BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.1 - ui- V1 1
9
-+J
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant a the requirements which must be met
pri toi.uanm°fa i0ateof Occupancy. Cit? Bf rm-p.rfino
Owner or au[hOricad agent Data TOTAL: ISSUED By:A,
fir, OFFICE COPY