20226r.
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: Vo
PERMIT NO.
20226 O^^6
tJs,.ar. Name: one:
Kea Lee,
CITY OF CUPERTINO-BUILDING
APPLICATION I PERMIT
BUILDINGELECTRICM4PLUMBINC-MFGHAMCAL
A A .
5-\ _
Cnntratter'.Name; j1 ue.N'
�IlE•J CIItN E U ,r7
CATEGORY
COMROLN
Arehitect/En neer
6 Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: 33(l I iYVT X151 , . ' 9S(J
PERNITISSUANCE
(U' ❑ 1:1 [:1LICENSED
�J
CONTRACTOR'S DECLARATION
I hereby affbmthit l am Recessed under provisions of Orapwr9(commenc.
Section 70W)ofINvislon3ofthe Businemand Pmfesdons Code, and my
license Is Ins fo and dfect. S O 6 J
Date Cylass �_Lic.p `I s
Dale .l •'ISG Contractor la,e t J t
ARCHITECTS DECLARATION
I understand my plans shall be used se public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I herebyaffirenthat I am exempt fromthe Contractors License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, site, Improve, demolish, orrepair
any structuretatemeits Chat he is alcensed pursuantof to
0e a signed statement that he a licensed pursuant it the proWsi00) of the
t the provisions
Con3 of tractors
usiLicense Lw refeener9(comCode) eringor that withxSection
theivi-
mpttherefem and
basis for the alleged n of exempt therefrom and
the baso !or the alleged exemption. Any vtolatbn of Section 7011.5 by any
Any violation
applicant for a permit 550(f.tsthe appgcanuo .doll penalty of net morethan
five hundred dollars he pr .
I,asowner llotework,Mor my employees with wages rtheresole
compensation, wllldothe work andthe stmcture V noHntended or offered for
sale(Sec.7044, Business and Professions Code: The Contractors License law
does not apply to an owner of property, who builds or improves thereon, and
who doessuchworkhimselforthrough hisownereployses, provided thatwch
improvementsaee notintended oroffered foreale. ILlemvew thebulldingor
improvement issold within oneyearofcompletion, the cwner-builderwlll have
thHLIxulds.of proving that he did not build or improve for purpose of rule.).
U S as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contractors Llcenae Law does net apply to an owner of property who
WImves
Wilda or prothereon, and who contracts for such pTiem with a
coykactow. IimnxN pursuant to the Contractor's Llrnnse Law.
P C for this reason
LJ I am exempt under Sec B k so
APPLIANCES -RESIDENTIAL
PANELS
]OB DESCRIPTIONingwith
, no tg
y�J
4I y 3
f, x �•y` S
J! r S' J io ' t.c f n(e
X11'1000 A.M[5
OVER1000AMPS
SQ. FT. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
TEMP. METER ORIOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURES
VALUATION
OU 0 r OV
NEW RESIDENI3AL ELECT2 SQ.Ff.
STORIES
bye4'r9-
TYPE CONSTRUCTION
JJ
I.-NtTT H Qxa w1
TOTAL -
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN k VEM-WATER (EA)
ICC, GROUP
RES. UNITS
FLOOD WNE
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a osetlReate of consent to self -Insure, or
ceAtfiuteofWorken'Compev tionIwuranuorarnrtiftedropythereof(Sec.
M00, Lab CJ !n
Policy N
DRAINS FLOOR, ROOF, AREA, GOND.
SANITARY Y_ N
RECEIPT N
FIXTURES PER TRAP
SCHOOLTAX Y N
RECEIPT#
CAS EA. SYSTEM -I INC -4 OUTLETS
PARK FEE Y_ N
RECEIPTp
Co
C.
copy V hereby furnished.
[—]Certified copy b filed Mth the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiseenlonneed not be completed lfthepermit isforone hundred dollars
($1I wdifyth
] certify that employ
permit is issued,othe
an person
I shall not employ any ,Lam In any manner w u to berme subject to the
In any manner so a to become
Workers Compensation laws of California. Date
Applicant
shouldNOTICEco �thisCvaffete Exemption,you
Lab or
shouldbecomesubjecttothe ply with
Compensation proisinprovuis Permit
Code you must forthwith comply with such provisions or this parmit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Ihercby Mork for w them bacoretmction lendingc. ,Cie.ncy C.) perform-
once of the work for which this permit b owed (Sec. 3097, Clv. C.)
Lenders Name
Lender's Address,
have ready is with pBotion ty d county tordinances
I,ecL - I hat Iagree
ison,Iagreeto .11 ownernanusaati matelamPERMR155UANCE
ath antes e d mat ation lam
o nt construction, and hereby authorize representatives of this
relating to enter upon property for inspection of C.pe rposes.
city to (Wo) agree to save,
a abovcmify an
(we) agree m save, maemmty an d keep harmless the City of Cupertino
against liabilities, judgments, mats and expenses which may In any way accrue
ago Wt said City In unsequence of the granting of this permit.
AA
GREASE/INDUS[RL WASTE INTERCEPTOR
BUILDING DIVISION
ISION FIESmuted
PLANCHECK FEE
PAID
Date Recei t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200Fr.
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID
Date Revel tq
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLNB.__SQFI',
TOTAL:
BUILDING 'E
TOTAL:
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
FEE$PAID:
ALTEROR ADD'IU MECH.
AIR HANDLING UNIT QO l0,ODO CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
Sigwwre of
DOUS r Date
HAZARDOUS
HAlARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous
material as defined by the Cupeaino Municipal Code, Chapter 9.12, and the
Flealt In and Safety Code Section 25532(.)7
r-1 Yes r] No
Will the applicant or future Wilding occupant use equipment or devices
which emit hazardous air contaminants as dented by the Bay Arca Air
Quality Management D❑istrid2
1?h N No
of
havereaa the haze us materials rcquf 25505, 5533 and 25534.
the Gllfomia Health &Safety Code, Sections 25505, 25533 and 7SSM. I
understand that lithe Wilding don not currently have a tenant, that it is my
nsponsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy.
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
I[EATING UNIT (TO 100,000 BTU)
_
Date Reuel t#
HEARING UNIT(OVFR 100,000 BTU)
TOTAL:
it 6
VENTILATION FAN (SINGLE RES ID)
ISSUANCE DATE
'
p" t
y+"D.��_.1+...__ L
ISSUED BY:_ �•�':a7-.1•aCR/1l
BOILER -COMP OFD' OR 100,M BTU)
BOfLER-OOMP(OVER 100,000 BTU)
NEW RESIDENTIALMECH. SQ.FT.
aL,Or authorized agent Date
TOTAL:
OFFICE COPY
7oE.t�sr�s PC-,
C�
NJi.V 3"cc Ea,l
EK S>E6�c.
APPROVED
IN ACCORDANCE WITH THE CITY Ot
CUPERTINO CODES AND ORDINANCES
DATE
SIGNED_�, l ��
This set of pans nd spec,r:cations MUST
be kept on the job ai all lanes and it is un•
lawful to make any c',anges or alterations
on same without w.w.,
permission from
the building Oepi., C.ty of Cupertino.
The stamping of .h:s Wan and specifications
SHALL NOT be head to permit or to be an
approval of the violation of any provisions
of any City Ordinance or State Law.
MAY 4 i 1991 D
SLOG. INSPECTION DEPARTMENT
CITY OF CUPERTINO