21949 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY .
Building Project Identification + PERMIT NO.
Building Address:
Sal ��f�-ttAF-V-Wcrnz %aL, 21. 949
A A
r'. rte ^• ZS3-'2 ane CITY OF CUPERTINO-BUILDING DIVISION :��L`' 1l
Contmet '.Name: Lie.No: APPLICATION / PERMIT
ar
BUILDLNGELFCTRICALPLUMBING-MECHAMCAL CATEGORY 'CONTR�I.g—
Architect/Engineer: Lk.Na t0"l7 -
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: LUU ELHUI PLUMB MUCH
PERMITISSUANCIi 1Z
LICENSED CONTRACTOR'S DECLARATION
I hereby aISaL El
ffirm that l am Ecensed under provlslonsar Chapter 9(commenc APPLIANCES-RESIDENTIAL, OBDESCRR'130N
Ingwith5eelon7000)ofMvlelon3afthe Busimmand ProfeasionsCodgand my -
IAsh Lk
full force and effect. PANELS
L.. A
It...Class .p O BL'-14 �'1t�,1 1,)
Date Contractor IM TO 2DO ANTS
ARCHITECTS DECLARATION 701-IMO AMPS
µqqµ!! 7 I understand my pians shall be used as public records. OVER IOOOAMPS SQ.FT.FL RAREA ''')$/SQ.Fr.
E (Cj Licensed Professional SIGNSELECTRICAL ( RV t�
6 OWNER-BUILDER DECLARATION SPECIAL CIl2CUIT/MLSC
I., a 1herebyafBrenthat lamexempt fromthe Collmdoe.Lkenselaw forth¢
following reason.(Sectlon 7011.5,Business and Professions Code:Any city or
� � countywhich mquimsapermltmmnstmMalte,,mprove,demolbh,orrepalr TEMP.MECEROR POLE INST.
anystmmmpriortalbbsuamc aborequirestheapphantfwsuch permitto POWERDEVICES
file a signed statement that he Is licensed pumuant to the provisions or the
�way Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi-
0� -sm3 of the Business and ProfesslonsCode).,that he besempttherefromand SWEstMING POOL ELECTRIC - VALUATION
Gthe basis for the alleged exemption. Any violation of Section 7031.5 by any / OUTLETSSWITCHFSFIXTURES C� (y
applicant for a permlt subjects the applicant to a civil penalty of not room than • L �j I —1 1
O five hundred dollars($500).
�n ❑I,as owner of ro a NEWRMENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
p p rty,or my employees with wages as their sole
compensation,willdothe wwk,andthe structurela not intended or offered for
,q sale(&c.7044,Business and Professions Code:The Contractor's License Law
2 does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RE£UNITS
who doessuchworkhavelforthraugh hisownemployees,provided thatsoch
Improvements arena Intended oroffered fwsale.If,however,thein ilding or TOTAL;
improvement swldwithinoneyearofcompl&ioMthe ownervbullderwlll have
tn�rdenar proving that he did not build or improve rw purpose of sate.). QTY. PLUMBINGPER FEE PLOOD?ANE APN
I,'as owner of the property,am exclusively contracting with Bcenand PERMIT ISSUANCE
de cam to construct the project(Sec.7044,Business and Professions Code:
C.ommeta's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
builds or Improves thereon, and who contacts for - -such ptojects with a FEE SUMMARY
actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec. B&P C for this reason
Owner DRAINSFl.00R,ROOF,AREA,CO SANITARY Y N
�� - Date
WORKMAN COMPENSATION DECLARATION RECEIPTk
FIXTURES PER'TRAP BCItOOL TAX Y— N—
❑I hereby affirm kers that I have a liummmificase
mc of consent d self-insure ora RECEIPT N
certdlabC.) rken'Compensatlonituurance ora certllied copythereo((Sec. GAS EA.SYSTFM-1 INCd OUTLETS
Poli Lab CJ PARK FEE Y N
Pollry p.
CamCny GAS F.A.SYSTEM-OVER 4 BTA) BUILDING DIVISION
ISION FEES
edified, copy is heed with furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy b riled with the city inspection division. ,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID —/
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1.. Date Recei t# S
CTNssectlon need no[be completed If the permit b(worse hundred dollars
($too)arlevJ' " WATER,HEATER W/VENT/ELECTR ENERGY FEE Y N
Icerilfythat in the performance oHhework foiwhlch this permit is blued, —
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREA.I.ING
Workers'Compensation Laws of California.Date PAID
O Z Applicant
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB._—SQ.Fr. Date Recei t# .wow
Hshould become subject to the Workers'Compamation provisions of the Labor - TOTAL:
f/9 Code,you must forthwith comply with such provisions orthis permit shall be BU1 DIN E �O
7 deemed revoked.
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE L
Z Iherebyaffirm that there b a construction lending agency for the perform- - TOTAL: ELECTRIC FEE
O once otthe work for which this permit is issued(Sec.3097,Civ. lQV
Q _ Lender's Nacre - PLUMBING FEE
IL Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImrtifythatlMvereadthlsappllatWnandmabthattheaboveinformation
I,correct.I agree to comply with all city and county ordinances andmatelaws 1 PERMTri55UANCE ��..� FEE-PAID,
} G relating to building ronstmch.s,and haebyautharb,representatives of this
(— Ncity to enter upon the above-mentioned property for inspection purposes. 'ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City or Cupertino Date Receipt#
(.1 .,.lost liabilities,Pdgments,come and expenses which may In any way amme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
.gabut sald City i nce of the granting of this permit.
en 20_91 AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Ignature of App nt/ ontractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUSMATERIAL DISCLOSURE
Will the applicant orfuture building occupant store or handle havardous HEATING UNIT(TO 100,000 BTU) 'Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the ,y
I 75537
lealth and Safety Cade Section fa)7 HEATING UNIT(OVER 1WObO BTU) TOTAL' —t,
❑Yes M No
Will the applicant orfuwm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) RAJ
4n Yes nn No 66'"'II!lJ6L
havcreadthehazaidusnuterialsrequiremenbunderChapler6.95of BOILER-COMP(OVER ICQ000 BTU) -
theCallfernaHealth&Saf,Code,Sections 755,25533 and75534.] Y MAR
!T �(] 7
understand that if the building does not wdentl have a twan that it ism NEWRESIDENTIALMECH. Fr Ills'! V `'J 1
responsibility to notify the occupant of the requirements which at be met
prior to issuance or a Certificate of Occvpa ary. '
Owner or authorired agent Date
TOTAL: ISSUEDHY:V✓
s�
OFFICE COPY