19502 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PWect Identlncatlnn PER.V(ITNO.
Building Address: 19502
Io.2oa- Mann Drl UZ CLJ e'r�I wo
Phone: A
(tic: iard CITY OF CUPERTINO-BUILDING DIVISION
Cenualm',Nana: Lie.No: APPLICATION /PERMIT I I I I f 90
I3 f, BUILDINGELICTRICALPLUMBING-MECFIANICAL CATEGORY CONTROL X`
Archltect/Engineer. Lic.No:
YnPlat CLW I ri QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address 1558 Nome5ka.d S . Clara. PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION WXX
I horcbyafflrmthat I amlicensed under provbionsof Chapter9(commenc. MPLIANCESFESIDENHAL JOB DFSCRQPUON
Ingwlth Soctku7000)of Divlslon3 ofthe Buslnasand ProfessionsCode,and my
license is in full to and d(cct. I PANELS I�s L
DateCoss Uctl a �y
Date � - O Contractor CassQ
ARCHITECT-51) CLARATION 201-1000 AMPS
cel I understand my plans shall Be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
u1 CO
() Licensed PnAessional SIGNSELECTRICAL n I
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC -7 8q ., is
L., Z IhercbyafRre,that l am exempt form the Contractor's License law forthe
0 t-p following reason.(Section 70715,Business and Professions Code:Any city or
uWl countywhich requires a permit to construct,alter,improve,dennlbh,or repair TEMP.METER OR POLE INST.
F rjr�� anystructum prior to its Issuance,also requlreathe applicam for such permit to
file a signed statement that he et licensed t to the bions of the POWER DEVICES
0.s gra pursuant provisions
Ort Contractor's License 30Sn rg^ Law(Chapter 9(mmmendwith
Divi-
SWIMMING POOL ELECTRIC
kon3o(theBusnessandPrfembwCoc)orth.thebeumptthemfmmad VALUATION
Ne basb forthe alleged exemption. Any violation ofSectlo70715
by any 51r, OU-ILETS-SV.TTCHFSFIRTURFS
applicant forapermitsubjecvtheappRcanttaadvil peratydnotmorethan a .0 g0,000
lindred dollars($500). NEW RESIDENTIAL ELECTR-SQ-Fr. STORIES TYPECONSIRUCTION
�
I,as owner of the property,or my employees with wages as their sok
�7.4 compensetion,wlll dothe work.and the structure is net intended or offered for
O sale(Sec.7044,Business and Professions Code:The Contractors License Law
S does not apply to an owner of property who builds or improves thercvq and OCC.GROUP RES UNITS
su
iforthrough hisownemployem,provided that ch `
Improvemantsare not intended proffered(orsale.I(however,thebuildingor, TOTAL:
p meet bsold withinoneyearofcomplctbn,theowner-bu0derwill have
thYrdcn of proving that he did not build or improve for purpose ofsale.). QTY. PLUMBI PERM14 FEE FLOOD ZONE APN
I,as
net of the property,am exclusively contracting with licensed PERMIT ISSUANCE 1'-1
contractors to construct the project(Sec.7044,Buslneas and Prdm essioCode: 4
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN (EA)
Wilds or Improve thereon, and who contracts fee such p(mjeats with a
M tactoHs)Rcensed pursuant to theContnctor'a Llrense Gw. BAIX FTA4�P D FEE SUMMARY
LII am exempt under Sec. B k P C for this reason
• Owner Date
l D NSFLOO ,A '1
SANITARY RECQPI'N
WORK MAN COMPENSATION DECLARATION �j SCFIOOL TAR Y N
❑1 hereby affirm that I have a certificate of consent to ctrl!-Inwre,ora I t7s® RECEIPT N
certificate mf Workers Comperuatlon Wuranre ora certlied ropythereo((Sec. G d UTL 2 CZ PARR FEE Y N
3800.Lab C.) RECEIPT N
Policy
Com any 4 BUILDING DIVISION FRES
Mottled copy is hereby furnished. s /I L EPTOR PLANCHECK FEE
�Cchifled copy bfiled with the city inspection division. ) AI d O /q ttl�
CERTIFICATE OF EREMPTION FROM WORKERS' G PAID NAV
COMPENSATION INSURANCE SEWER-SANITARY-SIO FA.200FT. Date RC i t#
(Thlsseation need rat be completed lithepen
rat pedt b for one hundred dollars
($100)or loss.) WATER tRFAT[R W/VENT/[L[CTR .Ca ENERGY PEE Y N
Icertilythat in the performance ofthework forwhich this permit is Issued, ^
I shall not employ any person in any manner so es to become subject to the WATER SYSTGI/TREATING R S I OA
workers Compensation Laws of California Date PAID 040 �/�1
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT.ILaher making this Certificate of Exemption,you
Fshould become subject to the Workers'Compensation provisions ofthe Labor Wtly-e,aA )}�._re.,'.N� TOTAL:
fA Code, most forthwith comply with such rovblom or thin permit shall be N'\moo TIOM'�G4�
W j dee dere.ked. Py P { � BUILDING FEE If
W a CONSTRUCTION LENDING AGENCY L `�-l� SEISMIC FEE Aga
CL Ihereby affirm that there ba construction lendingagency forthe perform ma�ks ELECTRIC FEE QyjO
D Z anceofthe workforwhichthb b WTOTAL:permit ued(Sec.3097,Clv.C.) O('�W
O O I<nderb Name PLUMBING FEE (�
F Undcr•.Add. QTY. MECHANICAL PERMIT FEE
U
I cenifythat l have read this application and kFEES PAID:
atethatthe above information ^ MECHANICAL FEE
Is comers.I agree to comply with all city and county ordinances and state laws PERMIT
O
Nrelating to building ematruelon,and hereby authorize representatives ofthls
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. 'C m Date Receipt#
(We)agree to save,indemnify and keep harMesa the City of Cupertino
V against liabilities,pcigments,mks and expenses which may in anywayacaue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against said City in consequence ofthe grentingofthis penniL AIR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTION TAX
QIe dA'6; �(.{A.L"IU4io I CONSTRUCTION TAX PAID:
Signatureof Applicant/Contractor Date ERHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT 00 100,000 BM Date RC eI 1#
material as de0ned by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and SafetyCode Section 25532(a)T HEATING UNIT(OVER 100,000 BTU) TOTAL: 1
❑ Yes , M No
Will the applicant or future building occupant use equipment ordevices VFNIILATION FAN(SINGLE RESID) ISSUANCE DATE
which rout hazndous air contaminants as defined by the Bay Arca Air
Quality Marsagement District BOILER-COMP OLT OR 100,0(0 BTU)
4 Yes No ehazs to ab regal under Chap er 6.95 of OLER-COMP(OVQ 100,000BN)
'I th carni Ina ! Code,Sect) 255 ,25S33.nd25534. 1
erstaoe
nd t 11 ngdsn rren haveatenant,thatitlsmy NEW RESIDENTIAL MECH. SQ.FT.
pansib'i t o fine imments which must be met
pr A ica • Oc ney. ,,
vy
neror authorized agent a�O ISSUED OY:��1't
TOTAL: tX
OFFICE COPY