19701 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
"Bulldin Pr°act Identification + - PERMITNO.
Building Address: - - - 19 1!//f.
0
�o2ai. Jo5gPH Cl2ctE Lo-T 8
ners ante: Phone:
3oSapa ax a: 2$$ •2078 CITY OF CUPERTINO-BUILDING DIVISION � ��O
C° radortName, 1J �•. Lm.Na APPLICATION /PERMIT
JO29S! BUILDINGELEC'IRICAL-PLUMBING.MECHANICAL CATEGORY
Architect/Engineer. _
It.N. V b(O
.ESO C -• f ' " R . UI NG
S QTY ELECTRIC PERMIT PEE BIPERMIT
Add.. Gpn Y (� LL141MO PERMITISSUANCE�; Eff -D
- LICENSEDCONTRACTOR'SDECLARATION -
I hereby affirm that l am licensed under provisions of Chapter9(commaic APPLIANCES-RESIDENTIAL J DF RR'IIUN
ingwith Section 7000)of Dlvision3ofthe Buslruvsand ljpftmsaonsCo and my
license is In fullgr and effect. PANES
Lima.Class kS Eleni —QZ r
Co �- f /^ �T L/� IwWr7v-r.]C
Date I .3� ntn —�!'—L�IV^.'Ar` UP TO 2DO AM
ARCHITE S CLARATION 201-IDODAMPS
qq�
92• Ionderstandmypisrushallbeuse m
aspubllcrerdw OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.++ O
Fi b 0 Licensed Professional SIGNS ELECTRICAL /81
(
<<�q OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC V•
Zt, Ihercbyaftlrm that lam exempt fromthe Contractors License Law for the
pp craddy hichrgirection7mtS,Businesand Professions Code:Mympair //'' �� 1s�s �L
TEMP METER OR POLE!NST. 460 ,.UY114..Yp�+ •
� countywhkh rcquiresapertNtmcotutrud,alter,improve,demolish,arrcpalr
a any a signercprior tents that heisaiso sed pursuant t the provisions
of its POWER DEVICES
file a signed statement that he is licensed pursuant to the proWloru of the
Contractor's License law(Chapter9(romm,icingwitecton )oIA-
O I'n with Section 7000of DIA. SWIMMING POOL ELECTRIC
IL. the basis for
the alleged xemptiori. Any enationthat f exempt therefrom and VALUATION
o' the Baan for the alleged exemption, Any t tolalmn of Salty not
by any OU7LETSSWITCHESFIXT(1RESpermit the applkan/loa tlAl penalty mnm more than
$
five hundred dollen(g500),
❑ NEW RFSIDFN7iAL ELECTR SQ.PT. ^
I,as owner of the property,or my employees with wages as their sole 7s./ STOIUES TYPE CONSTRUCTION
C compensation,w111dothe work.and thestructure is am Intended or offered for
'$�,O site(Sec.7064,Bust,•..and Profeskru Code:The Contractors Lt..Law
�$ does not apply to an owner of property who builds or Improves thereon,and R
who doessuchwork hlmselforthravgh hisown employee%provided that such O
improvemnb=nm Intended oraffered formle.If,however,the building or IOTA
me
improvent issold within one yeamfcompletlon,the owner-builder will have
MPQ
t1�k� enof proving that he did not build or Improve for purpose ofsakJ. QTY, PLUMBING PERMIT. FE pTppp pp /
U Lae owner of the property,am exclusively contracting with licensed
contractors to mnstmct the project(Sec.7014,Business and Professions Code: p)Bg1ITISSUANCE 2-- TE rf
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or Improves thereon, and who contracts fm such ptokc,with a FEE SUMMARY
cg6[fa.ctor(s)licensed pursuant to the C.amulm's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B h P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� -
- . Owner Dam RECEE7M ,
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL FAX Y N
I hereby affirm that 1 have o ]mum to of consent to seyther of m a RECEPI'M
!°ate ofWorkers'Compenaatlon lraurance ora artlfled iapythereof(Sea CAS EA,SYSTEM-1 INCA OUTLETS PARK FFR Y N'
3800,lab CJ
Polls'p RI:C[1I'f M
CAS EA.SYSTG40VER 4(FA)
Com BUILDING DIVISION FRES
Certified copyis filed
the city
d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE IS-OO
IgCedBled copy b filed with the dty IrupeRlon division."� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE'
Tfhiesedlonneed SEWER SANfTARY nor becompleted if the permit isforone hundraddollan STORM EA.200FT. Date Revel t#
(E1 DiodWATER HEATER W/VENT/ELECTR � ENERGYFEE Y N
I terrifylte that In the performance o(thework(orwhkh this permit Is issued,
I shall not employ any person in any manner so as to become abject to the WATTRSYSTEd/TREATING
Workers'Compensation laws of California.Date PAID
ZZ Applicant - NEWRESTDENTIALPLMB. SQ.Ff. Date ReCel t#
O NOTICE TO APPLICANT.,If,after making this Certiflote of Exemption,you
Hshould becomesubjcd to the Workvm
Workers'Compeation provBdoof the Labor TOTAL:
jr N Code,you=at forthwith comply with such provisions°rthis permit shall be BUIL DING FEE, 077. V Y
LU j deemed revoked.
D. CONSTRUCTION LENDING AGENCY SEISMIC FEE Q.•
Z Ihereby affirm that there is a construction landingagenry,for the perform- TOTAL: ELECTRIC FEE S•57
M ancaof the work for which this permit is Issued(Sec.3097,Civ.C.) �S
V O Lender's Name - - PLUMBING FEE
LL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Irertlfythatiha madthbapplimtlonandaatethattheaboveinfamutmn /t
a incorrect.I agree to comply with all cityand countyardlnancesand Natelaws PFRMTTISSUANCE 2— FEES PAID:
} y, relating to building construction,and hereby authorize representatives of this
F Z
city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MECH.
— (We)agree to save,Indemnity an If keep hernias the City of Cupertino Date Receipt#
a a1 ill bilitms;judgmenis'comm and expenses which may In anywayacaue AIR HANDLING UNIT CFO 10,"CFM) SUBTOTAL: '
rug tsaid Cityin consequenmofthe agtin of thispermit.
2 • 3'q a AIR HANDLING IINTf(OVER tO,OWCFM) CONSTRUCTION TAX
Igna of Applicant/Contmdor Data ! EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE - - I- 3
Will the applicant or future buiding oavpant store or handle haaardom IiEAT1NG UMT(TO 100,000 BT1p 0LP
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ 'Date RC[ei tk/
Ilealth and Safety Codes++-.-Sttection 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yen . u N°
Willthe applicant or funs building occupant use equipment or devices VFN771ATION PAN(SINGLE RESID) ISSUANCEDATE
which emit hazardous air contaminants as defined by the Bay Arca Air
. Quality Management District? BORER-COMP(31-B'DR100,(XD BTI!
4 Yet No
haveread earthhe Safety Codelflereonts 25505,sunder Chaplin 6.95 of BOILGR-COMP 100,0009TU)
thet Health&Safety Cod%Sectlomently haven 3 and meant,that
Rj j{(a 1 1990
understandtontifyhat if thfdmgdant nm a require e,rdsw which
that ltismy NEW RESIDENTIAL METH. SQ.FT. - In/'I1 y,
responsibility riortlestui to notify the i occupant of the requlrcmenb whkh must be rrNt
prior to Lsm nee of a Certificate of Occupancy. '
�)-:• 'City
Bf I'Imn
Owner or authorised agent Date ISSUED BYre
' TOTAL:
OFFICE COPY