20018 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification PFYMIT NO.
Buildin%1 14 20018
TM—nye—ro are: one; IE
4241,7"9— S �S�r 99 �y9s� CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lic.Noe APPLICATION /PERMIT —` L
BUILDINGELECTRICAI PLUMBINC-MWHANICAL CATEGORY C
Arehlte t/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE I��
11LOU EL PLUMB mk�ft
LICENSED CONTRACTOR'S DECLARATION
I hereby afflrenthat lam licensed under pernisonsof Chapter9(mmmenc. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwitht...1 Section force of Div effect.
fthe Buelresnand ProlnalonsCode,and my
Licersbin full force and effect. PANEIS
Laccase Cbz Lk.Y
Date _Contractor —UP TO 2DO AMS
ARCHITECT'S DECLARATION 201-10(sO AMP"'
NICO
understand my plain chin be used r public records. OVER 1030 AMPS SQ.FT.FLOOR AREA B/SQ.FT.
(7 Licensed Professional SIGNS ELECTRICAL
�6] g OWNER-BUILDER DECLARATION SI'ECIALCIRCUIT/MTBE
Iherebyaflmothat l am exempt from the Contractor's License law fir,the
o pp❑p (.lowing xawn.(Section 70315,Business and Prefesiens Code:An tl or
FZf'u( cauntywhichrcqulresapermitW.,stud,alter,impmve,demo h,arxpalr TEMP.METER OR POLE INST.`a 3 anY.Iuc .PHewlblawancgalwrequimstheappUmntforsuchpermlttu
6 file a signed statement that W in licensed pursuant to The provisions of the POWER,DEVICES
SSOu, Contraeme.License[aw(Chapter9(mmmencing with Section 7000)of Dlvl-
OVALUATION
e(on3ofthe Business and Prvf.i..Codc)arthal he brrempt therefromand SWIMMING POOL ELECTRIC
0 the basis for the alleged exemption. Any violation of Section 7031.5 by any /(�OUTLETSSWITCIffSFIXTUR S4 W O �v..,�X
�j oppllrantfees permit subjectsthe applicaotto a civil penalty of not afore than LW
6 Our i,.,o dollarshepr. " ir sets NEW RESIDENTIAL ELECTR SQ.FC, STORIES TYPE CONSTRICTION
G7 �n pensaownero(tthe werHy,ormy empbyen with wages as fferedfo
compensation, wink edl..Codurebwtintended orofferedfor
O sale(Sec.7094,Buelrssa and Professloms Cade:The Contractor's License Law
curious apply toanowner ofproperty who Wilds.,improveath,ren ,andOCC.GROUP RFS.UNITS
who doessuchworkhmxiforthrough hisownempleyees,provided that wch I
ngr TOTAL:
improvements are not intended oroffered fee sale.If,however,thebulldia
improvement bsold withinoneyearofmmplelloRtheowner-W Bderwll have
telan of proving that he did not build or Improve for purpose ofsale.). QTY, PL MIT FEE FIADDZONE MN
I,as owner of the property,am exclusively contracting with licensed pp pp lSSU E •'1 r+R
conn inns to construct the project(Sec.7019,Busher and Professions Code: la a!J
The Contractor's Llceneo Law does not apply to an owner of property who AL DRAIN&
Wild. or improve thereon, and who contracts few such Inu) with a FEE SUMMARY
ciD1l+ctor(s)Bernard pursuant to the Corhaam/s License Law. BAIX WPR .D CE
LJ I am exempt under Sec B 4 P C for this reasonOUTSIDEFEES
Avner
DRAINS P, ND. SANITARY Y N
Drte RECI7PC M
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y_ N
01 hereby affirm that I have a certificate of consent to self4ruttre,e a RFGEIPf M
/ arti(IcateofWmken'Compensatlon leeimeceor a certifed copy thereof(5ec. GAS.PA. -1 ING4
3800,Iab C3 s� PARK FEE Y_ N_
Policy Y ) RFRECEIPT N
Com any BUILDING DIVISION FEES
CGAS .SYSTEM-0VE cAlfled copy is hereby famished. GRGSE/INDUSIRL NTERcDR
E3CertUed copy b filed with the city Inspection division. PLANCE
HECK K�
CERTIFICATE OF EXEMPTION FROM WORKERS' 'CREASE)RAL /��,ICI PAID L.�FEFE����
COMPENSATION INSURANCE SEWERSANITARY SCO EA 2057 Date Recei t# {-10
•LCYQ�J
R)or lm.an need net hcompleted if the permit b Iororm hundred dollars
(sI W)arlyth WATER HEATER W/VExvFI Fr TR ENERGY FEE Y N
IxHifythat to the performance of the work forwhich this permit labored,
I shall not employ any person In any manner w r to become wbjed to the r r_O,9
Workers'Compensation LxwWATER SYSTEM/TREATING
sof California Date PAID LOJVy ^_
(30
Z Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Ff. -licant Date Recei t# nJ 17n
Fshould become subject to the Workers'Compematlon provblans.(the Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be BUILDING a
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE L
I herebyaffirenthat there is a comtwction lending agency for the perfomr TOTAL: ,rsp ELECTRIC FEE ,,OD
Z an of the work for which this permit b Issued(Sm.3097,Civ.C.)
LL LL u dens Addrer QTY. MECHANICAL PERMIT FE PLUMBING FEE
O W Icertifythatl have read this applicationand statethattheabovelnformatlon MECHANICAL FEE
IL bre
carct.l agree to complywlth all cityand mncrews
untyardbaand state laPERMIT ISSUANCE •�(•� FEES PAID:
relating tobullding constwctlon,and hereby aulhorlu repersentatives of this
.� U) dtyto enterupon the above�mentioned property for Inspection purposes. ` ALTERORADDTOMECH. Date ReCel t#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities,Judgments,cowsand expenses which may In any wayacaue AIR HANDUNG UNIT(TO 10,01DO CFM) SUBTOTAL:
agalrt said City In consequence of the gnnling of this permit.
t � �Cl>•RJ20ws LT��17/4Q `IR HANDLING UNIT(OVER IO,000GRIND CONSTRUCTION TAX
natunof Applicant/Contractortete EXHAUST HOOD(W/DUCT) 71 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllllhe appbeant or future building oompantstox or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t# �
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and SafetyCode Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
Will the applicant orbuildingoccupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
QILLIfty Management District? BOILER-COMP 0HPOR 100,000 BTU) 4=/'
Lj Ye ®{�INo
have read the haza"Mouamiteriala requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ta`� .Z
the California Health k Safety Code,Sections 25505,25533 and 25534.1 ( is P. J
undetstand that if the Wilding does not currently have.tenant,that it Is my NEW RESIDENTIAL MEIN—SQ—FT.
responsibility to notify the occupant of the requirements which must be met /�
prior to uancr of a Certificate of Occupancy. city of M
Own(/or authorized C
agent . _11+C/Wcos Da2_ te ISSUED BQ /t'�'xa'iwa/u""'
V TOTAL: t
OFFICE COPY