22477 (2) B.Ildi.,Pro ed Identification PERMITNO.
Building Add..,:
lo-?Co um. 'DF_-AW7_P' SUM. 22477
In...; F_:'APPLICAI1ONSUBMIIIAL.Al1i
0�0/yqzs CITY OF CUPERTINOLRUILDING DIVISION
on N Lk.No: APPLICATION I PERMIT
la- ot 10
BLqLDING-ELECTRICAL.PLUMBING.Mr�-CMNICAL CATEGORY CONTr
Lk.No:
,k,% . E
I "fl {a,.1;:IBUILDING PERMIT INFO '
':ELECTRICPERMITT
Address, LICENSED CONTRACTORS DECLARATION —PERMITISSUANCE F91 I
1 hereby affirm that lam licensed ta.det,provolone o[Chapte,11(cenmero,_APPLIANCFSRMDENML JOB
Ing with Section Division 3 dthe Butdoes..rd Profession.Cd,.nd my
I I...1,In full force and cited. PANGS
License Clam Jr.0 QW*W
Date Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS $/SQ FT.
I understand nnyphoushallbeused aspub4crecords. OVERIWUAMPS n Fr.FLOOR AREA
06 SIGNSELECTRICAL
Licensed Professional L44%07
OWNER-BUILDER DECLARATION S=IALCIRCUIT/MISC
I
hereby affirm that I am exempt from the Contractor's License Law for the
z C) following reason.(Section 71111.5,Business and Profession.Code:Any city., zP.M ORPOLEINST.
Oz a
rMc..ty.hich,.Nl. �
apettommtNa,alter,impm �
�deWh,ormpair
any structure prior to Its Isnuarce,alm requires the applicant for such permit to POWER DEVICES
ilk a4gord suaccoem that he Is IlMrsacl pursuant to the pmvLI.m.f the
Q6 p,y C."Inactor':Lic rn,Law(Chapt'r9(ommuncing with Secion 70()of Divi- 1SWIMMING POOL - RIC VALUATION
InnitBusine.sand ProficaioaCM10.rtlot oth..empttheefomand
the bash for the alleged exemption. Any violation of Section 70315 by any OUTLET&SWITCHE.S.Fl)(TURES
applicant for a Permit subjects the applicant to a civil penalty of not more than
H02
oil..($500). NEW RESIDENTIAL ELECTR—SQFr. STORIES
or of the property,or my employees with wages as their sok
,!he work and thestructure is not Intended or offered for qgo
C. it L
sale(Sec.7W4,'Bu a and Professions Code:The Contrautot's License Law
does not apply to an owner of property who Wild..,inpronn thereon,and 41,41 OCC.CROUP RES.UNITS
wh.doc...chwrokid.l(rathrough Ithoomccoplyeas,provided that such
Improvements are not Intended orof(ered for sale.If,however,thebuildingor Vl l TOTAL I 1
Improvement Issold withinoneyearofcomplelon,theowner-builderwiiI have T.—
en of proving that he did not build or Improve for purpose ofsale.). OTY. FEE%,I__TUN513—ZONE nrN
,Was owner of the property,am exclusively contrading with licensed Co
PERMIT ISSUANCE
co 0 tract a
tract.n to construct the project(Sec.7044,Business and Prorfessions Code:
The Contractor',License Law does not apply to an owner of property who ALTER-DRAIN Is VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for suchpWjej"". FMSUMMARY"r
cM with
" 1�"
dodWiceried pursuatotheContractor'sLima's Law. :
C15rt
1 am .e.ps under SM.— B &P C for this Mason BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,ARIV&D� SANITARY Y_ N
Owner Date REC _
EIPT If
WORKMAN COMPENSATION DECLARATION I SCIJOOL TAX Y_ N_
M,hereby affirm that I have a certificate of consent to sot(-Insure,ora RECEPT a.
cemifimito(Wor��C=pe�llonl�u�nceora certifiedcopythemor;c. GAS-PA.SYSff-1 U4CIPMETS PARK FEE Y_ N-
38M,Lab C.) RECEIPT I
Policy N C;A*J&AbA OVJ�MA) BUILDING DIVISION FEES
C any
ffCcAlf1W copy ts hereby furnished. PLANCHECK rE&,cc(,9
F-1 Certified copy is filed with the city ipcdi..division. sA'fv sT1yrRcFTaR 3/ qV7 9
CERTIFICATE OF EXEMPTION FROM WORKERS' I (A IV
COMPENSATION INSURANCE I -SJNFpA)ft/SY0Qf Fj.ZIFT-1 Date Remi W
(This ardi.o need not b completed if the permit 6 for one hundred d a
(SIM)mIrsa.) A ERGY FEE Y
permiti.h. ATEROONIrMW/
Imrtify shat In the perfarnance.(rise work for whkhthls 4 _T4E1j)C% I& I
.IN. ATERSA+/4fATIt '1 -1
I shall not employ any person In any Manner so as to become subject to the PAID OOf 47
Workers'Compensation Laws of California.Date
0 Applicant x_ Date R I t#
Z z NOTICETO APPLICANT.-IL.fter making this Certificate of Exemption,you NEWRpMFT1AL1P&BV__,
shmldbecomsub�dtotbeWorken-Compo�atlonprov�to..fth�L��r — TOT..
VT Codeyou=at forthwith comply with such pnovisima or this permit shallbe _ BUILDING FEE
> dMcned rev.kcdl. SEISMIC FEE
CL a CONSTRUCTION LENDING AGENCY
zI hereby affirm that there Is a construction lending agency for the perform, — TOTAL, fo7,_&c_ ELECTRIC FEE
0once of the work for which this permit h Issued(Sec.3W,Civ.CO PLUMBING FEE
LcoAce.Name
LL Lotold'.Addre.. QTY: MktiAi4eAU,P,'ERMIT; ,�FEE MECHANICAL ITE
U Icedifythatt have read this application.nd stanethat the above information
0 lU Iscoord.I agree to comply with all cityand county ordinances and statelaw, PITMITISSUANCE CaW FEES PAID:
>. Q. relating to building construction,and hereby authoden repoMcniatives.41Mh
d1yt.crM,.po thc.1Wve-rM,rdI.mcd property for lc.pcd].n purpose. ALTER OR ADD TO MECH. Date ReceiEt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
O against liabilities,judgment,cmM.rd..p,,rsxs which may inaryway.odue AIR FIANDLING UNIT GO 19.000CFM) SUBTOTAL:
ala Ci 11 (the Ad it PF It CONSTRUCTIONTAX
n1plAeMos AR onto AIR HANDLING UNIT(OVER 10,000CI-M)
XO "pe
Signal A WIAUSTIIOOD(W/DUC CONSTRUCTION TAX PAID:
CT)
pp c"`�ATFRIA III
I-IMiMaJS I� r�U R 0 j
o a. I ban 1� . . a
Willtheapplica I or future building occu an t e rhan leo.res HEATING UNIT(TO 100,000 RTIA Date Rixeipt#
e ban", ap ——
the
mattrial.,defired bytin,Cupertl..M.nicipa note, h,ple,9.12,and the -2
ET.Ith..d Safely Code Section 25532(x)7 HEATING UNIT(OVER Iffl,"1110 TOTAL-
E�Yea . nNo — VENFITLATION FAN(SINGLE RESID) ISSUANCE DATE
11111ho applicant or future building occupant Use equipment ordavlocs
which emit h.,,and....I,,..t.mm.nha,dcfl.ed by the Bay Area Air — BOILER-COMP 01 IP OR 100,000 BTU)
Qu a lity Ma na Bement Dist rid?
No —
qh Y"'Mad the bazall�us Materials requirenrents u oder Cha Fier 6.95 of BOILER COMP(OVER 100,000"TO) PAJO
the C7iffe,n1.1i,,.Ith&SafetyC.de,Sedi..25505,25533.nd25534. I — NEW RESIDENTIAL MECIL-92.1'r K.
understand that If the building does not currently have a tenant,that It Is my
responsibility to notify the occupant of the requirements which=at be met — E P 2 4 90,11
prior to Issuance of.Certificate-(Occupancy. I_qt
ISSUE
Owner or authorlMd agent Date TOTAL "'IT DBY:4_VVP-- �
OFFICE COPY