19699 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Idrmmcatmn PERMIT NO.
Building Address-
5
aI n r n n
05EP b6 C,R_ 1_b
nera aces: y� Phone: p
CO:TvS l XArt HSSt7G , Z$S''ZC7 CITY OF CUPERTINO-BUILDING DIVISION a//3/?O
cert annraName: 11 Llc.No: APPLICATION / PERMIT
A IM.E S L� a SI SSC S O_z SS BUfLDINC-ELECTRICAT PLUMBING-MECHANICAL CATEGORY CONTROL a
ArcM1ltect/Engineer. Lk.No
���--aaa�L O _r , v C, O QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO'
Address �T}'a'i w Qy PAD C PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATIO LL__ll
IWreby affre,that l am licensed under provisions of Chapter 9(commusec, APPLIANCESRFSIDENML OBDREMON
Ingwlth5etllon 7000)of Dlvinlon3o(Ihebusinemand ProfeaslonsCode,andmy
LI lamml and effect. �" ,-'., PANELS ` C7 /� TQCjJa(JjuISU
Llanse Clam V7 LInM Q SS
Date/ Contract
"CHI SDE LARATION 701-1000 AMPS
re - OVERIODOAMPS FT.FLOOR AREA $/SQ.FT.
OO ]understand my plaeu shall publiercrords. c-Q
Licensed Professional SIGNS ELECTRICAL ;Z 34•,— LI V I N 71`4
{�C�! ,OWNER-BUILDER'DECLARATION �/� a (y
,O i -e Y city
TEMP. LCRtCURPOL I 4-OO GQIWCfL= 0. 87
.a 'IhereB a!(Imnthat l am evens fromlhe Contra cto License orthe
collosum mace.(Section a permit to Business and Profess sCodn: d or gp3pp METIX OR IDLE INSf.
county which tequimapermlttorosutrvct,alter, Prov de rrepalr
q� anystrutture priorm its issuance,also tequlresth ppb t suchpermltto ROWER DEVICES
ES 5 file a signed statement that he la Ilmosed puriC to t vis the _
3w Contractor's License Law(Chapter 9(commencin I km vi- SWIMMING POOL ELECTRIC
OJ e(on3o(the Business and Pro(emio-C .)ort at J.;exempt th d EVALUATION
�"•7 the Wide for the alleged eaemptldn. ny vial o Section y //•�(
applicant fora permit subjects theapp cant to 11 RY of flan 0[TILE7SSWITCHESFTX7TJRES / 1[ "
live hundreddcllzrs fthe ). NEW RESIDEM7ALELECTR SQFf, �j,� TKIrs Cl V WPECONSIRUCT70N
nI,ae owner of the property, oycn 1 w es a thele sole
rompensatlon,willdotM1e or it dare len 1t ed or offered for .'.23
0 sale(Sec 70K Business and Prole i e:Th mums.License Law
(1j$$ docanotapplytoan ownero(pro ywho Wlld I Proves thereon,and - 'OCC.GROUP RES.UMTS
whod—suchworkid Borth hhisownemPloy ,provldedthatauch - • oa
improvements are not Intended orofferod twsale.If,however,thebullding or TOTAL: '
improvementiswldwlthlnoneyearofcompIOWMthemner- fiderwlllluve -
t rden of proving that he did net build or improve for purpose oleate.). Qi-Y. PLUMBING PERMIT FTE PIME,7ONE APN
�L as owner of the property,am exclusively contracting with licensed PII ISSUANCE, /9 ^
rontracmreto rorseWctthe project(Sec.7044,Buaneu and Profemlow Code: .. . v
The Contractor's License Law does not apply to an owner of property who
WALTERDRA4N&VENTWATER(U)
builds or Improves - -
'thereon, and who contracts for such piojeats with a FEE SUMMARY
N¢t(factor(s)licensed pursuant to the Contractor's License Law. -
r(5l am exempt under Sec. B&P C !or this BACK FLOW PROTECT.DEVICE Q1 FTuI III!Prrq
Owner Data
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
- RECEB'f N
WORKMAN COMPENSATION DECLARATION FEcTURES PER TRAP M40OLIAX Y - N_ ,
• e�yy�I hereby of/less that I have o artificers of Consent to selfdwre,ora i - RECEIPT N
3800,Ubc.) orken'Comperoatlonlruurann me certified copy thereof(Sec. GAS U.SYSTEM-]INCAOUTLLTS PARK FEE Y N
3500,Lab CJ
Policy M .�ss� - RECEIPT
Cr
Cam anY__ N, t-" GAS EA,SYST[•3d-0VER4(U) BUILDING OIVISI NFEES -
Certifiedcopylsherebyfumished. t, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCIIECK FEEN�y pp
Certified copy is filed with the city inspection division. G 0q,.0
CCRTIFICATE OF EYEMPTION FROM WORKERS' GREASE TRAP ' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM U.7(IOT, Date- RCCLI tit
(Thls.ectlon need notbcW completed edg lithe perMt Vlor arae hundred dollars
(5100)orfy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill not that In the person In
mannerhework so as tobehb pesubjecmit is blued, /�y
I shall not employ any person In any manner n m to become subject to the
Workese'Compmsatlon Laws hWATER SYSTEM/TREATI
o(Calilom
. Date NG PAID
0 Z Applicant NEW RESIDENTIAL PLMB: SQFI'. ��' - Date Recei t#
Z O NOTICE TO APPLICANT:ILaRer rraking this Certificate of Exemption,you
should become sub)ect to the Workers'Compensation provisions of the Labor TOTAL:
C y Code,you must forthwith comply with such provisions orthb permitshall be BUILDING FE
`> deemed revoked,
IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL - Ihxmbyafflrmthat them hi a emstructlon lending agency for the perfnrm - ELECTRIC FEE '
7 Z arm of the workforwM1_kM1thioperitdtlalsmed(Svc.3097,Clv.C.) TOTAL: v` - p.L•7
U O Lander.N.me PLUMBING FEE
LL F- Lander'.Addmsa QTY. MECHANICAL PERMIT FTE MECHANICAL FEE
O W funifythatl Wvereadthbapplimtlonandstatelhaltheabove lnformatlon
incorrect.l agree to comply with all city and county ordinances and state lawn PERMIT ISSUANCE FEES PAID:
} 6 relating to building construction,and hereby authorize representatives of this
N to enter upon the above-mnnlloncd property for Inspectiontion purpose., ALTERORADDTOMECH. - a
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino - DatC RCCeI [d
city
V against liabilities,judgments,rostsand expenses which may lnany,wayacrne AIR DANDLING UNIT(TO 10,000 CFM) SUBTOTAL•
-I
Wt said City In consequ nceaf the antmgof this peIt.
wZ 90 AIR HANDLING UNIT(OVER too9BCFM) CONSTRUCTION TAX
tum of Applicant/Contractor e EXHAusi HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE - -
Wllltheappiicantorfuture building occupant afore or handle hazardous HEATING UNIT(TO 100,0110 BTU) Date ReCei IN
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Coderc.S�ection 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Y. U No
Will thea ppllcant or future building ocup.m use equipment or devices VRM7UTION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined bythe Bay Arca Air ' I: v
Quality Mawgement District? MOILER-COMP OL'IPDR 100,000 BTU) '" 8D
4 Yea d No I
have read thehazar cue matedala requlrementsunderChapter6.95of- BOILER-COMP(OVEKI00,000 BTU). O Q(IiI
the California Health&Safety Code,Sections 25505,25533 and 75534. Lf 1' � as JU
understand that if the building does out currently have a tenant,that it is my NEWRFSIDENTIALMECH. SQ.FF
responsibility to notify the occopant of the requirements which must be met -
priortolasuanceof a Certificate of Occupancy. _ City Qf,r11nQrt1110
Owner or aulhorlud agent Data - - - ISSUED B2 'I•�•as'�Idl s
TOTAL: f
OFFICE COPY