23238 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMWTNO.
Building Addms
YVA ao yoo MAI?/AAj, ' AUS . 23238
Owner aName: one:
CITY OF CUPERTINO-BUILDING DIVISION �����
Contractor's Name: Lic Na. APPLICATION I PERMIT
T BUILDING-aKTRICALPLUMBING-MECHANICAL CATEGORY CONTROLM
Architect/Engineer. Lic.No:
QTY ELECTRICPERMrF FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONIRAROr pr DECLARATION
I heh Sectio irmthatla Asion3ofthe usinemand Pmf hamsCocommmc APPLIANCES— L f JOB DESCRIPTION
ingwehSettlors 7W0)oflaffeon3o(thegualneesand Prolesslom Code,and my
license Is In full(o�'e�d affect. n PANELS ✓�
Lim Class L-��sCl Lic.# S 9/2
ate 1-30 —Contranar f�6 Uv/7i�.S .
ARCHITECTS DECLARATION 20I-] PS l
LppLqq re O 0 I understand my plans shall be used as public records. COV I "I's SQ.FT.FLOOR AREA S/SQ.FI'.
E o Fj Licensed Professional 'I 'ELECTRICAL
w OWNER-BUILDER DECLARATION
fn fhSPFLIALCRiCUIT/M15C
IhcrcbyalBmnlhatlam exemptfrom the Contractors Liceriae Law for the
7O9FQ following reason.(Scdlon7W1.5,Bu.ineaand Pmfeaslona Code:Anydty or TEMP.METRORPOLEINST.
fr5�� countywhich requires a permitto construct,alter,bnprove,demoilsh,orrepair
yy anystmcture prWto Its lesuance,also requfreathe applicant forsuch permit to
MPOWER DEVICES
C file a signed statement that he is licensed pursuant to the provisions of the
Contranora License Law(Chapter9(commenting with Section 7")of Divi- SWIMMING IDOL ELECTRIC VALUATION
sfor3c,fthallusinevand Pmfealons Code)orthat heVexem therefromand
Q$ the basis for the alleged exemption. Any violation of Seellont 7031.5 by any OUTLR' SWHCHFSFIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPF.CONSTRIIC7'ION
I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure U not Intended or offered for
❑
to(Sec.7614.Business and Profmions Code:The Contractors License Law
r$ does not apply to an ownerof property who Wilds or improveathereen,and OCC.GROUP RIS.UNITS
who doessuch work himself orthrough his own employees,provided that such
Improvements are not intended oroftered foroale.If,however,thebuilding or TOTAL:
improvement 6sold wlthinoneyearofcompletiaMthe Owner-WRderwlll have
th,q*Nen of proving that he did not Wild or improve for purpose f.k.). QTY. PLUMBING PERMIT FEE FLOOD ZDNE APN
LJ L as owner of the property,am exclusively contracting with Iicented PERMITISSUANCE
contracted;to construct the project(Sec.7094,Business and Professions Code: l
The Contractors Llcenae law dean net apply to an owner of property who
Wilda or Improves thereon,and who contracts for such ptojeds with a ALTER-DRAIN&VENT-WATER(EA)
cq➢I ctorUd licensed pursuant to the Contractor's License Law. FEE SUMMARY
Ll I am exempt under See B& P C for thin reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR.ROOF,AREA,CONTI. SANITARY Y_ N_
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby a(finn that I have a certificate of consent to self-Insure,ora RFLEB'f k
certificate of Worken'Corepersaticn Insurance orammfled copythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3g00,lab C.) 4J-S�- Z_' /�G RFLFII7a
Policy# I oC GAS PA.SYSTEM-OVER 4(EA)
Core BUILDING DIVISION FEES
eNOed copylahercby fumbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECRFEE
Certified ropy U filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAIT PAID
ON INSURANCE
I
COMPENSATSEWER-SANITARY-STORM EA 20OPT Date Recti t#
(Phissettlorsneed na PENS lRthepermit Vionone hundreddollars
($100)or less) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I mrtlfytha in the per(ormanm of the work forwhich this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workcn'Compenwtfonlaweof Glifornia. Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z NOTICE TO APPLICANT:ILager making this Certificate of Exemption,you
H UI should become subject to the Workero
rs''Compereation pvisims ofthe Labor TOTAL:
Code,you most forthwith comply with such provisions rrthis permit shall be BUILDING FEE
LU _ deemed revoked.
CONSTRUCTION LENDING AGENCYSEISMIC FEE
Il Ihcrebyaffirmthat there is a construction lending agency for the perform TO � ELECTRIC FEE
7 Z arca of the work for which this permit is tssued(5m 3097,Civ.C.) PLUMBING FEE
V Q Lenders Name
LL F Leedee.Addmss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfythatlhavemadthbappliutionandstatethattheaboveinformation
4odect.l agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
r y relating to building construction,and hereby authome representative of this
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cu Pertino Date Receipt#
V against liabilities,atdgmenb,cons a nd expenses ch may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againnu Ity conaeque o(th gran' ofthla pe '.
v 3a 9J AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
SI of Appb, ontract Date EXHAUST HOOD"/DUCT)
CONSTRUCTION TAX PAID:
HA2ARD0 MATERIALS DISCLOSURE
Will the apphont or fur building aavpant store or handle hazalloua HEATING UMT(TO 100,000 BT11) Dat Recef !#
rrvterial as defined by the Cupertino Municipal Code,Chapter 9.12,and the
1 lealth and Safety Code Sedion25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: �
❑ Yes , M Na
Will the applicant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ' #(I� N(U9/990p,DATE
which emit hzTardous air contaminants as defined by the Bay Area An MPI a'i
• Quality Management District? BOILER-CAMP DHPOR I00,IX0 BTU) k(pak{ys�'�'(
Yea he n No `TTY 1{1t�V N V
4havematl ealth&rafus etyC de,SeregW 25505, 5533order nd2553Chapter 6.95of BOILER-COMP(OVERIOD,000 BTU) �/Y#d17 UpO
the California Heath&Safety Cods Sections 2550.5,have
a t and 25534. 1 2
understand that if notihe fy
the ing doesoccupant not mrequire encs tenant that b met NEW RESIDENTIAL MECH. SQ.FT. /s
responsibility to of a theoccupanto!the requirementswhich most be reset CI1 I' lrlrLwi`7
prior to Issuance Ola Certificate ofOmpanry. UF GUYtnIIryV
Owner or autemind agent Date
TOTAL: ISSUED BY�
OFFICE COPY