20071APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identificatl® -
Bu leling Address:
PERhITENO.
z CV-IS-ro ler
2007.1
rU WL 6A -e L,/2 e.
CITY OF CUPERTINO-BUILDING DIVISIONL
APPLICATION/PERMIT
'
U —'Z�!
Contractors Nanr Lk. No:
OBUILDINGELBCTRICAL
`LIZ
PLUMBINGMECI CAL
CATEGORY
CONTROL r
Arrhfiect/Engineer. +.. No:
_
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add. v� Mlrs r�` C
PFRNUTISSUANCE
El
LICENSED CONTRACTORS DECLARATION
I hereby a(llrm thellam Bcmeed underprovlsionsor Clupter9 (cortvnm
ingwith Section 7000)d Dblsion3 ofthe Buslrcssand ProfesdosCcel ,and my'
license is in full force and effeeL
APPUANCRSRFSIDFIJIIAL
)OB DPSCRIPTION
yaf —IS I
PANES
Licee Cb® Lb. a
v
Date c,mmTIator
hG [
2M-1"-1�
OVER 1000 AMPS
AACHEGTS DECLARATION
I undentaM cry plans shall k used u public records
1 \ E. & CSI. /Q—�vl'1—W2,4
`
. SQ. FT. FLOOR AREA $ FT.
//gg��
SIGNS ELECTRICAL
LicensM Professional
51'ELIALCRCUIT/h1LSO
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
TEMP. MEITROft EWSI.
=ntywhkhreuimap70 wBualneaLer,impme,Code Mydtyor
mm�tywhid rtqulmspemdt tocouMruct, ilter,improve, demolbh,orn,pilr
mynmcturt photo ltslwavice,abo requtresthe appllant for ouch pemNt to
file a signed seement that he b licensed pursuant to the provisions of the
Contracture License law(Chapter 9(commencing with Section 7000) of Divi-
slon3 of the Business and Prdmbns Code) or that he Is exempt therefrom and
POWER DEVICES
g(Vamm; POOL ELECTRIC
VALUATION
Est basis for the alleged exemption. Any violation of Section 70315 by any
appH.t fora permit subjects tha applicant to a civil p reby dnot mon, than
OLrr=SW1TCIE1iHXHIRES
'
NEW RESIDENTIAL ELECTRFIORl6
Eve hundred dollars (5500).
F�1, as owner of the property, or my cmployen with wages ae their sole
TYPECONSTRLCTION
mmpenselon, wW dotk work, anathesiouchure h not Intended or offered for
sale 0. 7011, Business and Professions Cade: The C.Nrad.e. EA.. law
,
does not apply to an owner d property who builds or Improves thereon, and
whodnsu
och work himself orthreugh hlsownemployen, provided thatuuch
C.GROUP
RFS UMTS
Improvemerds are not intended oroffered for sok. If, however, thebullding a
Improvement, bold within omyearofcomplellon,theowner-builderwlll have
TOTAL:
t rden of proving that he did not bund or improve fee purpose of sale.).
L as owner of the property, am exclusively contrectbg with licensed
c ntnetos to construct the project (Sm 7010 Business and Profeabro Code:
QTy. PLUMBING PERMIT FEE
"lDNE
PERMH ISSUANCE
D
AI'N ,
The ContnGorb License Law don nut apply to an owner of Property whcALTER-DRAIN&
builds or Improve thereon, and who contracts for such plojec, with a
9111:1+ctoms) limned pursuant to the Contractors License taw.ARY
LJ I am exempt under Sec B & P for b re
VEE- WATER �
FEE SUMM
BACK FLOW PROTECT. DEVICE
QUrS I DF FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RFCMT r
Owner
WORKMAN CO kNSAT10. RATION
❑I hereby affirm C I have a l.r o consent to
3800, Lab of workers' Compensation Irwurance oa cenlrlM ropy thereof (Sec
3800, Lab C)
FIXTUIffS PER TRAP
SCHOOL TAX Y_ N_
RELEUrI' r
GAS EA. SYSTEM -1 A'C10UTLE15
PARK FEE Y_ N
PT
GAS EA. SYSTEM -OVER
Comr
�� y
DING DIV
BUILDING DIVISION FEES
( ICertlfied copy b heed withmWud.
LF�JI Cenlfied copy, n(Ilea with is city inspection alWelon.
GREASE/INDUSIRL WASTE INTERCEPTOR
P CHECK FEE .
GREASET�r
CERTIFICATE OF EKOV PTION FROM WORKERS'
PAI
sEwER RAN rARYSTORM FA. 20(FIr.
COMPENSATION INSURANCE
(rhls scc[lon need not be completed if the pemdt tr for one hundred dollars
Date Rcoe( IN
(SI f10)olca.)
Illnot tlut In the (hewok pemdtic blued.
WATER HEATER W/VENT/ELECTR
ENERGYVEE Y N
sorwMch co
cracm In
I shag not employ any.Lawn b any manner at a to become object to the
Wwken'CompenuatbnLwso(GWonla. Date
WATER SYSTEM/TREATING
-
PAID
ApplicaNOTICE.
Da[e R I (7l
NEW RESIDENTIAL PLMB. SQFI.
NOTICE b TOnr sub a to t: a after making this eioo Arte of Exemption, of t ion, you
shonldkmrtrsubject to the Work en' Compewtbnprovhbrooftk Labor
T AIL
hwhh comply with each prwbbra or this permit shall ho,
Code,yourevoked.
deemed rewked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
IhercbyalOmnthettkrcbamnstructlon lendingagency forthepenarm
an. of the work for which this pcmdt is Issued (Sec. 3041, Clv. CJ
TOTAL:
ELECTRIC FEE
Sender, Name
Indere Addrew
I certify that) have read thlrapplTotbnaM steethat theeerve information
Isco ect. lagn,ato comply wtthaB tltyand muntywrdWnmand date laws
QTY. MECHANICAL PERMIT FEE
PLUMBING
MECHANICA FEE
F
-
PERMIT L'SUANCE
FEES PAID:
relating to building cormsualen, and hereby author,,c representatheea of this
city to enter upon the above-mcntloned Property for Inspection purposes.
(We) agree to rave, indemnify an d keep harmless the City of Cupertino
agerat llabWtin,jrdgmenacrestsard expense which mayor any.y..c
agabst sed CRy irymnsequenn d the granting d tits pe
/
(uJorn�t/eruenetere si• /moi'
ALTER OR ADD TO MUCH.
Date ReCei [M
AIRHANDLING UNIT (TO 10,=CFM)
SUBTOTAL:
AIR HANDLING UME(OVER 10,000CRA)
CON RUCTION TAX ,
;01 Y'
Si nature orA Date
g pp
E%I IASIST HOOD
CO
CO TRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HFATINGUMT(T0100,0DOBTU)
Will theappliant or future buRding occupant norewrhandle haaardws
material., defiod by the Cupertino Municipal Code, Chapter 9.17, and the
Date Recei t#
000
HEATING UNIT IW,,BTI.
� TOTAL:
on 7553x(.)1
.I Yn SectionSafety Code Slo
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
-
Will the appliam ix, building oempant use ayuipment or devices
which enct harardoue er contaminants as defined by the Bay Area Air
BOTIFR-CAMP OHP OR 1W,"
Quality Meutgement District?
Yes nn No
Tuve read the h anruoue matenalr requ lremenb per G
under Chap95 of
BOILER-C0141,(OVER 100,0(0 am
Ihe California Health&Safety Code, Sectiom 75505,25533 and 25531. I
understand thatlfthebulldingdmeamrrently have atenant,the itis my
responsibility to notify the occupant of the requirements which `rust be met
((p1 r, C
Fif 1
'
NEW RESIDENTIAL NIECE SQJ
prior to issuance d a Cenlfivte ofoccupancy.
U7 11 rtl artinn
ISSUED BY:]j.__LT�Vl
Owner ser authMud agent L Date
_ TOTAL I
OFFICE COPY