20432 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT,PEN ONLY
Building Project Identification PERMIT NO.
Building Address: f")0 A ^n
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rs ams. - HONSU A
AMfS a uK3w
/SC V4 CI-fYOFCUPERTINOBUILDINGDIVISION 2� /O 10
co t etur'.N.me: Lie.No. •APPLICATION /PERMIT J 0
BUILDINGELECTRICAt pLUMBINGMECIIAMCAL CATEGORY CONTROL Q15--
ArchltM/ ginar. - Lk.No: v
Q, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: �s�s s r.� X
PERMITISSUANCE 1.2"00 El IPLU
MB M�H
Lm tNS EOCONTR under provisions
Thereby affirm that lam licensed under wamiP ff Wmar9(rommenc MI'LIANCESRESIDENTAL - JOB DESCRB'IION
Ingwir ISI full 7W0)ofd effeon3a(thcBusinessand ProfessimaCode,and my -
licenselsinfull( sand t(M. PANELS
Llans�Class _ LI[.M
Dates. GO r— -
ARCHITECTS DECLARATION OVER 1000 PS
AM
�G I understand my plain ehaB be used m public rerords. OVER 11100 AMPS - :.�.`.Q.FT.FLOOR AREA 5/SQ.FT.
ww O SIGNS ELECTRICAL
U Licensed Professional Ys I
G V
Q m OWNER-BUILDER DECLARATION
In rFi, SI'FLAL CBtCU1T/MISC
1.., IhisgresBlrmthat lamexemptfrom
ossa Contractor's License Law(wthe "VI
7Op � county wreason6eaper permit
Business and Professions Codc:Anycttyor TFAIP.MEH7i ORPOLE INST. ��, (�•\1•�/
gZ county which requlrmapermit tomretrue,alter,improve,demoWh,orrcpalr
Ko'< tre anystr„ uprimrtm Its lssuance,abo requlreatheappllcan(for such permit to POWER DEVICES
6 U file a signed statement that he 19 licensed pursuant to the provisions of the
Q3rc
Contractor's License Law(Chapter9(com
meneng with Section 70UJ)of Dlvi- - VALUATION
�i SWIMMING POOL ELECTRIC
O elmn3olthe 8uslnmsand lsrofessions Code)orrhat hebexem thercfromand _ -
~ yd the basis for the alleged exemption. Any violation of Section 7031.5 by any I O (Jar
.PPBcant fora permit subjects the applicant to a evil penalty a not more than OUTLETS-SWITCHES 1 �A f�
ti O five hundred dollars(SM. _�;p _ tOZ. ISTOIU6S v Typ CONS'IRIICTION
NEW R[SID[NTIAL ELECIIt�_�.FI'. - ALE D i i�
p.-fin ❑enaownero(thep work,. d my employes emI tended r their sole
k7Q
compensation 7&n,wWdothe work.andthestmde:TsnotintcI.?.or offered for
$�2 dosule(See7044,Bualnewnerof property
Code The Comprovestherson,and
s Llcenx law ,
5$ whodoesauchtoanownerofproughhisonempbuilds orimproovidedthatsuh TS
wprovementsam khirreelfedmetered hisowne.If,ho eprovidedthatsuch
ass
improvement issold ithindneyear Remoraale.the owevep deerhe building have TOTAL:
Improvement proing within M did out
porImrove e for puposerwWhave
IlLj L as o neer of the pre did na exclusively
orlmp contra purpose with(cense QTY. PLUMBING PERMIT }T APN
Ltr 4 as owner of the property,am.70K ash.and Pro with licensed PERMIT ISSUANCE
coe Contratocomtcen the project,nor apply
to an owner
Iof pro ons Cade Z-
TMContractors .the Law does h apply a anowner ppropertywho ALTER-DRAIN -WATER(EA) .
builds r Improves thereon, and who mntraats!w such ptojem with a FEE SUMMARY
cgl1l[actor(s)Irexempt under Snt to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B A P C for this reason
DRAINS FLOOR ROOF,AREA,COND. 'SANITARY Y_ N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP , SCHOOLTAX Y_ N
❑I hereby affirm that I have a arti(fate of consent to self-Insure,or a RECER'I M
mtiflwteof Workem'Compemationlmuranaora.ruffed copythereo((Sec.
38M,1, GAS FA.SYSTEM-1 WC.40UTLETS PARK FEE Y N
4 8_W1er
Policy rbC)Ej(,gyp. S C- l JJ GAS EA.SYSIiMAVER 4(EA) RECI]I'I'M
Com any BUILDING DIVISION FEES
Certified copy Is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
MCertB (J
ied copy Is ed with the city Imps tion division.
L
CERTIFICATE OF EX'eMP1'ION FROM WORKERS' CREASETRAP '. PAID S�lD'-W S (}s-1�
COMPENSATION INSURANCE SE-VvFR-SANITARY-mRM EA 200pI Date Reeel t#
(TFlssection need not be completed lithe permit isfor casehundred dollars
($lW)wlesa.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
- Iartlfy that in the performance of the work for which this permit is issued,
I shall not employ any present In any manner so as to become subject to the WATQ45YSTG1/TREATING
Worken'Compenaation laws of Calllamb. Date PAID S-1C7lsa S7 a�� ^�
OZ TIft
Applicant NEWREADGNTIALILMO. D sQ.Fr. 1 �2 Date Recei t#
Z O NOTICE TO APPLICANT.If,aer making this Certificate of Exemption,you
Fshould become subjettothe Workers'Compematlon provisions ofthe Labor - TOTAL: a
� NCode,you most forthwith complywlth such provlsluia orthis permit shall be BUILDING FFE
W > deemed revoked.
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE _
Z Ihereby affirm that them b a construction lending agency for the perform DL
ELECTRIC FEE ,Q2..
ance of the work for which this permit b issued(5ec.3097,Civ.CJ TOTAL: 11; ELECTRIC EE - DZ
LL O Tenders Name TY. MECHANICAL PERMIT FEE
LL f l.cnder'a nddmss Q MECHANICAL FEE - /y
OW Imtifythat l have reacithis applicatmnand starethat theabove infor .tion '�,�,As3
a Isarmt.i dgreeto comply with all city and county ordinances and gate laws PERMIT ISSUANCE ,2-.W FEES PAID:
relating rebuilding comW ctlog end hereby autbomze representatives,of this
H N chyto enterepon the above-mentioned property,for Wpectlon purposes. ALTFRORADDTOMFCH. -
? (We)agree to save,Indemnify an d kap harmless the City of Cupertino Date Receipt#
L) agaln.01.1,11irs,pdgments,costsand expenseswhichmsymanywayaceruc AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a bald Clty In rons yuence mf the nti of this pertnlr.
p � AIR IiANDLING UNIT(OVFA]O,WO CFM) CONSTRUCTION TAX
c V �J1�n.y
Slgmtumof/s ppliccal�nt/Contranorf Date^ EKHAUS'I'HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMAV.RIALS DISCLOSURE
Willtheapplicam orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
rlealrhand safetycod a oa 25532(.)7 HEATING UNTT(OVER 100,000 BTU) TOTAL:
Ym No
Willthe appilmt r rebuilding wcvpant use cqulpmenrwdevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE�I L• 4.l
which emitharardu air contaminants as defined by the Bay Area Air BORER-COMP OFR'OR 100,000 BTU) PMD
Qu a Iity Management Distrl
4Ym o
have read the haz ou rerials requirements under Chapter 6.95 of BOILER-COMP(OVER IOQ000BTU)
the CallfornbHe.lth ASafstyCode,.Loom25W5,25533and25534.I ,
understand that lithe building does not ourently,have a tenant,that it is my NEWRESIDENHALMECH.I�SQ.FT. 2.01 AUG 2 M
90
responsibllityrontifytheoccupant o(the Imments which most be met
prior to Issuance ofa Certificates of0c an
MW of Wfi
O
m
term thotud agent Date TOTAL: Q ISSUEDR
OFFICE COPY '