23769 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prued Identification PERWT NO.
Building Add mea:
015-6 23769
'Owner. a : one:
(�, CITY OF CUPERTINO-BUILDING DIVISION
Contractors Na f Vu Lie.N« APPLICATION /PERMIT
LZ VV BIXLDINr—ELM WCA41'LIIMBINGMECHAMCAL CATEGORY CONTROL
•Arhitect/ 177
Lk.No:
L PERMIT INFO
t QTY ELECTRIC PERMIT FEE BUILDING
naareae:
PFRNUTISSUANCE }). ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION ChON 1_Q
I herby Sootioi 7000)o Div Bcensedunder peensannsafChapter9de,and(commume.y APPLIANCFSRESIDENTIAL JOB DESCRUMON
"cone"hSection 7000)6!DiNston3 mfthe Bualneaaand ProfeWonsCode,and my '
Ilarve la In fuB Jprq{gdUfM. Lj� r, ,. �/ PANELS C '�
Licensee Chss / N"y LIgM
Date GanhaQOr UP TO 2DOAMPS
ARCHITECT'S DECLARATION 301-IOW AMPS
OZO I understand my plyy.hal�u�i_ .1,11c remrds. OVERIOWAMPS SQ.Fr.FLOOR AREA f/SQ.Ff.
Licensed Profeg..l ��{'il�J SIGNS ELECTRICAL
t�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C
PF,"ZI hereby a(@mthat Iamexempt from the Contractor's LlanseLawforthe
0� o fallowing reason.(Section 7031.5,Business and Professions Code:Any city or
I"� county which requhnapemdttoonnstmct,altar,Improve,demolleh,orrepalr TEMP.METERORPOLEINST.
fag anystmmmpdortoiblmance,atsorequimstheapplimntfwauchpermltto POWER DEVICES
F s file a signed statement that he is licensed pursuant to the provisions of the '
3 w Contractors License saw(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC VALUA'fj�i—
E% J skm3 ofthe Businm and Professlose Code)arthet he is exempt therefmmand / J
6 the basis for the alleged exemption. Any violation of Section 7MIS by any 11 OOtl
applicant fora permit subjects the applicant to a civil penalty of net more than OUILETSSNTTCHFSFIAI'UEt15
five hundred dollars($500).
I,as owner of the pre", NEW RESIDENTIAL ELECTR SQ.Ff. STORIES TYPE CONSTRUCTION
compe�n ❑ p peaty,or my employees with wages see their mit
sale(Sm
707tion, hudsalhewwk,andth.Code: leant Wended oroffendfor
sses not apply
Profevbns Code:The Contractors Lenon,ad
�$ whodoc...ch torn owner ofproperty
rough who Wildsoyees,pvnthereatand OCC.GROUP RES UNITS
whodoessuchwork himself a Ihmugh his own e.If,ho�e Provheb thatsuch
Improvements areset Intended earofco !wale.If,however, flder ldingw
improvnmentbsoldwlthlmmneyearofcomplNlory theowner-bullderwillhave
tlA-Ifurden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively=trading with licensed ppZM)TISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code;
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER
buiMa or Improv.therm.,and who mmrCa for such pUajects with a FEE SUMMARY
OW
t[ttrn(a)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N -
Owner Date RECER'I a
WO KH AN COMPENSATION DECLARATIONH%'NRFS PER TRAPSCHQQL TAX Y N
C31 hereby affirm that I have.artlftcate of consent to self-Insure,ore RECEIPT'
certificate ofWorkem''Compematlonlruunna ora certified copythereof(Sec.
3800,LabC) S GAE.A.SY PARK FEE Y N
Policy p RECENT M
Cany GAS FA.SY BUILDING DIVIS ION FE IS
omMCertified copy is hereby th the city CREASE/INDU INTERCEPTOR PLANCHECK FEE
❑Certified spy V filed with the city inspection division. 10
CERTIFICATE OF EXEMPTION FROM WORKERS• CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date ReC i tat
(Thlsartlon need net be completed If the permit b for om hundred dollars
(SI00)ml..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I artily that In the performance of the work for which this permit is issued,
Isbell nw employ any person In any manner w as to become subjectto the WATER SYSTEM/TREATINGWorkers'Compensatlon Laws of California.Dale PAID
0 ---6ate Re�ipt#
Z Z. Applicant NEW RESIDENTIAL PLMB. SQ}T.
O NOTICE TO APPLICANT.If,after making this Cediliate of Exemption,you
should become subject to the Worker Compensation provfelom of the Labor TOTAL:
Up
Code,you=at forthwith mmply with such provisions orlhls permit shall be BUILDING FEE
�+
W C darned revoked.
CL CONS ere bt res LENDING AGENCY SEISMIC FEE r
I hereby af=2 w there l9 a mnstroctlon dlending(Sce. agency for the perfomv ELECTRIC FEE
0 Z anaafthe workforwhkhthb parmitV blued(Sec.3097,C1v.C.) TOTAL:
02 lanaereName PLUMBING FEE
IL I— La.dara Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Icertlythatl have read this appllcemnand statethattheaboveinformation
6 bmrrect.l agreetm comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives of Mla
1" Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date RCtot
— (We)agree to save,Indemnify an d keep harmiss ethe City of Cupertino ae CeIP
against lWbillties,judgments,mala and expenses which may In any way accrue AIR HANDLING UNIT((010,000 CFM) SUBTOTAL:
ago Wtaaid�tyi.c, sequenr ofthggp tfZ.fthbpergdit AIRHANDUKGUNIT(OVERI0,0D0CFM) CONSTRUCTION TAX
Signature ( p"Bcant/Contrartor lyI' Gdl t/O Date EXHAUST HOOD N/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recef 1N_
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(007 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yes M No
Will the applicant or it m building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air comamlmnts as defined by the Bay Area Air
Qua ilty Management District? BOILER-COMP OFR'OR 100,000 BTU)
4 Yes 11 No
have read the bazari mus materials requirements under Chapter 6.95 of ROILER-COMP(OVER I00,000 RTIA
the Califor it.Health A Safety Code,Srxtkms 25505,25533 and 204:1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr PAID
rmpruc bllity to notify the occupant of the requiremanls which moat be met
prior to Issuance of a Cendficate of Occupancy, s
Owner or authorized agent Doe
TOTAL: ISSUED BY:
uwV
OFFICE COPY