20989 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PIR.4Br NO.
' Building Address: f")O
ZZ-7 7(D MfJ?C�(�r�S G
989
wners ams:
1200 92-SS CITYOF CUPERTINO-BUILDING DIVISION ��? -9a
Contractors Name: N 1/ , Lk,No: APPLICATION / PERMIT l I
5'¢ZS'L'L hitect/En gUILDINGdECTRICALPLUMBINGMECFIAMCAL CATEGORY CONTROL.
Arc
gl neer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I7-3(e CH x., PERMITISSUANCE ly ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of Dlvislon3ofthe Buslnessand ProfesslonsCode,and my
Bcenx is in full�foma and effect. PANELS S (�
.Icen.Cbm S'; Lice S 47S Z-L TZIF4 11-
Date9/7Ieast.. Contract C-vs,SSIL 1G' UPTO2DOAMPS
WARCHIT DECLARATION OVER1000AMP5 SQ,Fr.FLOOR AREA $/SQ.Fr.
O 7. I understand my plaru shall be
be usus ed es public records
O
Lkenxd Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION
Ina SPECIAL CIRCUIT/MLSC
7t 7 Ihereby affirmthal l am exempt from the Contractors License Law for the
following reason.(Solon 7m15,Bu.inem and Profeselons Code:Any city or
O F'8 c ntywhlchrequtmaperr ttommtmd Atenlmprov,demolbh,orrepair
5 TQdP.MEIPR OR TOLE INST.
S � anystsuctum prierto its Issuance,alaorequires theappBcant forsuch permit to RAWER DEVICES
E��� file a signed statement that he is licensed pursuant to the proWloru of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O slon3ofthe Business and Professions Code)orthat heb exem therefroand
the basis for the alleged exemption. Any violation of Section m 7031.5 by any OUTLETS-SWITCHESHXTURES
6i applicant for a permit subjects the applicant o a civil penalty a net mom than
five hundred dollars($.500). NEW RESIDENTIAL ELECTR �'�
$ 6 nl,as owner of the property,or my employees with wages as their wk
c ' STORIES TYPE CONSfRLCT10N
ompensation,will do the work and the struenum Is not Intended or offered for
r5� ❑ sale(Sec 7046,B ouracss and Profesvlow Code:The Contactor.Licamlaw
k'3$ don not apply to an owner of property who builds or improves thereon,and OCC.CROUI' RES.UNITS
who don suchwork himself orthrrugh his own employees,provided that such
improvements are not intended orof(ered forsale.If,however,thebullding or TOTAL:
Improvement issold withinoneyearofcompldio,theowner- flderwill have
L"rden of proving that he did not build or improve for purpose ofsalea. QTY, PLUMBING PERMIT FEE FLOOD TONE APN
L f L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
..i.e.to construct the project(Sec 7044,Business and Prefresioru Code:
The Contractor's Llcenx law does net apply to an owner of property,who ALTER-DRAIN&VFM-WATER(EA)
Wild.or Improves thereon,and who contacts foe such ptpjvea with a
<qW(+cuu(s)lkensed pursuant to the contractors LI...Law. FEE SUMMARY
Uf am exempt under Sec B k P C for this reason BACKFLOW PROTECT,DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,CONO. SANITARY RECEIPT N
WORKMAN COMPENSATIONDECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a ceniBate of consent to self-Insure,or a IRECEIPT N
comfiateo(Workers'Comperuatlon lnsuranceora certified copy thereof Ike. GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y_ N_
3.ficy# 07 33 6Z0 — 90
CAS EA.SYSTEM-OVER 4(EA) RECEIPTDI a
Com env KmfK` BUILDING DI VISION FEES
OCertlfied copy Is herebyfamished.the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECICFEE
OCenBled copy V Iliad with the city Im)xatlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date ReceI t#
flNssectlon need net W completed If the permit Is forone hundred dollars
($10t4orleva WATER HEATER W/VENT/dECTR ENERGY FEE Y_ N_
I cartifythat In the perforenanceof the work forwhich this permit is heard,
1 shall net employ any person N any manner n as to become subject to the WATER SYSTEM/TREATINX;
Workers Compensation Laws of Califon. Date PAID-
0
Z Z
AIDOZ Applicant NEW RESIDENDAL PLMB. SQFI'. Date Remi t#
Z O NOTICE TO APPLICANT.It,after making this Certificate of Exemption,you
should become subject to the Workers'Comperuation provisions of the Labor TOTAL:
J) Code,you most ion hwithcomply with such provisions orthis permit shall be BUILDING FEE to
' deemed revoWvl.
Itl > CONSTRUCTION LENDING AGENCY SEISMIC FBG
d G Ihereby affirm that there l9 a construction lending agency for the perform- TOTAL: ELECTRIC FEE
7 Z arm afthe work forwhlch this permit is Lsssed IS..309'/,Cie.C.) PLUMBING FEE
O O 1,ander'.Name
IL I— Lc.dars Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 cemlylhat l have read thisapptirationand statethattheabove Information 12� FEES PAID[
d iscorrect.l agreeto complywith all city and county ordinances and state laws PERMIT ISSUANCE
>. relating to building censtmctlon,and hereby authorise representatives ofthis
F V) city to enter upon the above mentioned property for inspection purposes. ALTERORADDTOMECH.
Date Rxcipt#
(')
(We)agree to save,Indemnify and keep ethe City of CupertionagaWtliabllltlea,jadgmenb,c,Ksand expenses
which
may In any wayaccrue AIR]LANDLINE 11MT(TO 10,0XI CFM) SUBTOTAL:
against sa yinm�sryuenecofthe ant Ing a thl.pemsit.
r /�� 9' AIR xnNouNG UMT(OVER l0000cFM) CONSTRUCTION TAX
Akkd
Slmture of Appllan/contactor `Dat E(HAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardoes HEATING UNIT(TO I00,W0 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - r
I lealthind Safety Cion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 6
M Yes o
Will the applla"or mmbuildingoccvpantumequipmentordevicm VENDIATIONFAN(SINGLERESID) ISSUANCE DATE
which emit us a r contzmbunts as defined by the Bay Area Air pp
Qua lity Mawgement District? BOILER.COMP DFTPDR 100,000 BTU) PAI®
4Yes o
have read the haze ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
the California Health IMy Code,Sections 7550.5,25533 and 25534. 1
understand that if the building does not currently have a tenant,that It NEW RESID=- ALMECH. SQ.FT
responsibility to notify the occupant of the requirenne is which most W net
priorto bas Certifies of ccvp
X / 9 fit- f+Ipertino ��J
ncr or slathorimil agent Date TOTAL: I `k—k Y—
Y ISSUED BY:
OFFICE COPY