22251 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PU"T NO.
Building Address: n C
204 �flN I AVE . G /APPLICAHUNbUBM11 IAL2J
�ame.IstDM(L � 11,
2'/ — an� CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: 'JfdO LIe, a. APPLICATION I PERMIT (7
BUILDINGELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL p %^'3 1
Architect iner
/EngeLIc.N. , --36
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: EWWTISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DE2,LNU9 ION
IncnictSection force of Division ofthe Buslmssand Pro(easlonaCode,and my ^
Bronx Is InFulltom farm and effect. PANES t/"�7-P\'`In, •—/�
License Class LIc.x eV (/1
Date ContnRor �'L� l '
ARCHITECTS DECLARATION 201-1000 AMPS
7 I understand my pizv shag boosted as public remrda. OVER I OOO AMPSESQ'F�FT.�R�W 'FT'
O ALE�j Licensed Professional SIGNS ELECTRICAL N
C Q OWNEReBUILDER DECLARATION $1'ECIALCEiCUIT/ =SAO M P 1y�
uull Ihereb a(Orm thatlam exem from the Comranor'e License Law for the
9 t- following recon.(Section 70115,Business and Professions Code:Any city Or p O LE INS .
cas ntywhich requiresa permittomvtmot,alter,Improve,demolish,orrepair
q11g� anystmenom pdorto its lssuance,alsorequlres the applicant forsuch permit to POWER
6 ce file a signed 4atement that he V licensed pursuant to the pmvislov of the
Contractors License Law(Chapter 9(commencin with Section 7000)ofOwl-
30�^ slon3ofthe Businnsand Profeniov Code)orthatt hebexempttherefvmand �� L C VALUATION
y.'Sthe basis for the alleged exemption. Any violation of Section 7071.5 by any OUILETSSWI7C FI%T'UEtES 23 (/
applicant for.permit subjects the applicant to a civil penalty of eta rtnrc than
$ Ilvc hundred dollars(5500. NEW REEDENITAL ELPGTR SQ.F7F. STOWES TYPE CONSTRUCTION
c
I,as owner O(the property,or my employees with wages as their sole
ompevatlon,willdo the work and the structure b not intended or offered for
5 ❑ axle(Sec 7044 Business and Professloru Code:The Contractors License Law
$ don not apply to an owner of property who builds or 7mpmvm t hereon and OCC.GROUP RIB.UNITS
a who donsuchwork himselforthrough hisownemployees,provided that such
Improvements are not Intended proffered formic.If,however,thebuilding or TOTAL;
Improvement iswidwithin omramfcompinion,theowner-bu0derwill have
en of proving that he didnabuild orlmpmve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD IDNE APN
as owner of the property,am emluslvely mntraning with Licensed pE4M17 ISSUANCE
tractors to mvto d the Pon (Sm.7046,BusNesa and Profassiav Cade:
Contractors Llcenx Law does nn apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
lou 41s or Improves Hereon,and who m.trann for such ptojects with a w
cgIIV+ctor(s)licensed pursuant to the Contractor's License Law. BACKFLOW PROTECT.DEVICE FEE SUMMARY
I_f 7 am exempt under Sec. B&P C for this masonOUTSI DE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT
WORKMAN COMPENSATION DECLARATION ppLNRFS-PPR�iwr $CIiODL TA% Y_ N_
❑I hereby affirm that r have a certificate of consent to ulf.lnsurc,ora RECEIPT X
certificate ofWmken'Compensation Insurance ora certified copy thereof(Sec.
3500,Lab C.) S GAEA.SYSTEM-1INCA OUTLETS PARK FEE Y N
CoRECE
liry X GAS E.A.SYSTEN-OVER 6(EA) DING DI N
Cm anyBUILDINGPT VISION FEES
[1Certlfied copy b hereby foorklsd. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified mpy Ls filed with the city Inspection division. I Y?-Z' „
CERTIFICATE OF E%EIH PITON FROM WOR KERS' GREASE TRAP PAID l
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT Date RecciptN
(This xetion need not be completed lithe permit isfor one hundred dollars
($10)orless.) WATER HEATERW/VENT/ELECTR ENE'RGYFEE Y_ N_
I certify that In the performance of the work forwhich this permit 1s issued,
I scull not employ any person In any manner so as to become subject to the WATER SYSTIM/TREATING
Workers Compensation m
LawsafCallfoia.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. �]rf. Date Recei tt7
Z NOTICE TO APPLICANT.11,after making this Certificate of Exemption,you 1 .
shauldbemmembjentothe Workas'Compevatlonpwvtsiovofthe Labor V� TOTA
LU L:
CC N R
Code,you most comply with such provisions orthN permshall be V �� BUI ING FEE
j - deemed revolved' SEISMIC FEE
tL _ CONSTRUCTION LENDING AGENCY
<LO Ihercbyaf(Irmthatthem 0amvtmnlon lending agency for the peAorm TOTA . ELECTRIC FEE 'c1J
:) Z arm Of the work for which this permitb Wued(Sec.3097,Civ.C.) I
CC o
02 Lerde'eNama PLUMBING FEE W _
LL I- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Icenifythat l have read this applicationand statethatthe above Information
O W Iscormet.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. IL relating to building construction,and hereby authorlu representatives of this
F 2 city to enter upon the above-mentioned property for tvpecdon purposes. ALTER OR ADD TO MECH.
Me)agree to save,indemnify a d keep harmless the City of Cupertino Date ReceipHl
V agai+uthabil caI menta,cost Mexpenseawhkhmayinanywayaeaue AIRFIANDLINGUNEECTO10,000C17M) SUBTOTAL:
against sad C yi nsequen grantin this peragainst
AIR HANDLING UNIT(OVER IO,MOCFM) CONSTRUCTION TAX
A CONSTRUCTION TAX PAID:
Igna ureof Applicant/Contractor Date EXHAUST HOOD tW/DICT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hacardovs HEATING UNIT(TO 100,000 BTU) Date Rec�t41
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - -
Ilealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,W0 BTU) TOT
F1 MNo
Willtheapplicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air mntamlnanb as defined by the Bay Arca Air
Quality Management District? BOILER-COMP DH P OR IOO,”BTU)
Yes No
have mad He hazy pus materials mquirements under Chapter 6.95 of BOILER-COMP(OVIiRi W,000 BTU)
the Califrn la 7lealth&Safe Cods,Sen lona 25505,25533 and 25534.1
understand that if the building don net currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQTT. ��"` I„J(
rapomiMlity to notify the occupant of the requlrcmenls which must be mel
prior to Issuance of a Certificate of Occupancy.
�4!9f Cyunttim�t
Ownerorauthorin agent Data ,TOTAL. ISSUEDI3
OFFICE COPY