20075 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proed Identification PERMIT NO.
Building Address: 20075101571
�i 2- V �7/�li
wnera ante: -o7ne�;
1�-d If (L C - ,3 / �/ CITY OF CUPERTINO0.BUILDINGDIVISION _ Z� D
tndor'e Name: UILie.Ns APPLICATION / PERMIT
'VI�b1�' BLDINGELECTRICAL-PLUMBING-MECIIAMCAL CATFLOR CONTROL X
Architect/
77-617--e— Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Adtlrerea: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prwLvlons of Chapter 9(cemmenc APPLIANCESRESIDENRAL ]OB DESCRIPTION
Ingwllh Section 7000)of DiA.lan3ofthe Businemand Pmfrssi.m. oae,and my
license is In fun form and effect. PANESLlm / -
Date lam Lich I„w, K T
Date Cantndor V •R �
ARCHITECPS DECLARATION 201-IODOAMPS I\ J
qwq1� PA
09z Iunderstand my plain shall be used as public record& OVER1000AMPS SQ.FT.FLOOR AREA
E (Oj Licensed Professional SIGNSELECTRICAL
«< LtAu OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
Zs, Ihembyaflrmthat l am exempt fromthe Contractors License law for the
fallowing resson.(Section 7mlS,Buslnessand Professions Code:An d or
r unlywhich requires permit to mwtruct,alter,Improve, m
ve,deollah,orre4, TEMP. OR Sf.
ro
< anyslmc mprbrlaits Wuamealsorequlrrstheappllmntfurmch permit to
ruG U file a signed state. ent that he h licensed pursuant to the pro isk2 of the POWER S
Ow Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi.
30 Men Sof the Business and Profemiom Code)or that he tat exmpitherelrom and SWIMIAN E.R VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
<� ppuntforapermitaubjectstheappncantloadvilpemltyofnm=mlhan OUTI.E ES
° n ndmddollarsCSSM.
as owner of the property, NEW RFSIDFNTIA ECTR_SQFT, STORIES TYPECONSMUCTION
�n p eek,a or he employers with wage as their sole
< cele(Sm.11on,Businesa.131 do the wmkanssionsmdurehn ontraMdorcense Law
° sale(Sec.7mq to Businessand
pupeora Code:The CimpAevn Liremelaw
�'j $ whodardoes A& such oanownerofpropertywhoWlmplds orlmprovnthereoryand OCC.CROUP RES,UNITS
CC.• whodocesuchwarkhimsellarlhrough Msownemplayeea,provided that such
improvements are nct Intended oroffamd formic.I1,1e rover,thebuilding or TOTAL:
Imprpvement hsold withinUeyearofcompletion,t W owner-builderwill have
,cyTQI:n�Ls(TI/�rdcord provingthat he dldnMbuOdorbnpmveforpurposeofuleJ. QTY, PLUMBING PERMIT FEE FIOODZLINR APN
L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
tradon to rod mtruthe project(Sec.7074,Business and Professions Code: la�• 7
The Contractor's Lim.Law don nal apply to an owner of property who ALTER-DRAW kVENT-WATER tTA)
Wilds or Intp(Ours thereon,and who roAt. . (m such ptoprn Ith a
actor(-)/lunsd puna t to the ContractWs Lkxaxf�.aw FEE SUMMARY
I Sempt under kyyC or tE. aeon BACK FLOW PROTECT.DEVICE
net to•
.T DRAINS FLOOR,ROOF,AREA,COND, SANITARY Y N RECEIPT
O KMANIh S ON IA t N �/ FIXTURES PER TRAP 0O SCHOOL TAX Y N
❑1 hereby affirm that I have o re s oleo conxnt to self-Iopyt re el s L1 RECEPT M
mrdfimte o(Worken'Compematlon unnre ora certified ropythereof l5ec. GAS EA.SYSEDH-1 INC4 OUTLETS PARK FEE Y N
3803,lab CJ
Policy p RhCLIPf N
Com a CAS-EA.SYSfAf-OVER4(EA)
Y BUILDING DIVISION ITIS
Certified ropy is he d with the
ed.city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy h filed with lM city Impedlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE
(TNssectlon need Am becompleted ifthepermit hforonehundreddollan SEWER-SANITARY-
STORM RA.70OF1'. Date Recei t#
($101))
I WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
redBy that N the performance of thework forwhlch this permit Is issued, —
I shall not employ any person In any manner so As to become subjed to the WATER SYSTEM/TREATING
Workers'Compensation Laws of Calfomia.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB.I FT. Date Remi t#
Z NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers Compensation pmvisiom of the Labor �C� n^ P TOTAL:
d
V) Ce,you must forthwith complymi
with such provisions or this Pert shall be LLlX nCZ e )
j deemed revoked. /I��
La CONSTRUCTION LENDING AGENCY (wx.(J , SEISMIC FC•E
I herebyatO rm that there b a mmtmetion lending agenryforthe peri.``.. �a� � /f TOTAL: //II ELECTRIC FEE
� Z ance olthe work for which this permit is[awed(Sec.3097,C11,C.) rye/ ` .Fy
00 Lenders Name PLUMBING FEE - D
LL F Handers Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O hcerW Imdttythp
atlhavercadlhhapuHonandatatethattheabovelnformatlon
1 rect.l agreeto complywith all dty and county ordinances and Mate laws PFRMHISSUANCE FEES PAID:
>_ `clak"C"I'l
dingromlrtactlon,and herebyauthoronemprexntalivesofthis
(— 2 enyon the abovemention property for Wpection purpoxa. ALTERORADDIOMECH. Date R2Ce1 f#
to neve,Indemnify a keep harMem the City of Cupertl
V u'p certs rad xpa.seswhichmayi.anym a AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL•
,,As
lym cram the antinglor nth It ATR HANDLING UNIT(OVER IB,afXCFM) CONSTRUCTION TAX
lure. pp0mnt/Contractor EXHAUSTHOOD(w/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DI LOS
Will lheappilunl or future building occupant sloreorhand aaa HEATING UNIT(TO 100,000 BTU)
matenalaa defined by the Cupertino Municipal Code Chapter 9.17,and the Date Recel t# ,�ss//��
Hcabhand Safety Cd Ion 75537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ^vo
❑ Ynbr No
Wiillheappllcanl lure building occupant use equipment or devices VENT]ATION FAN(SINGLE RESID) 1 DATE
which emit harardmim
ous air centant.as defined by the Bay Arca Air BOILER-COMP DFI'DR 100,000 BT
• QualltyMamgementDlsl 7 U) N?R 2 1990
Yea ig No
vereadtheelmEnh a oet materials reons 2555,2553 and 25534.
a! BOILGR-COMP(OVEt1m,000 BTU)
the lifornla F7ealth k5afety Code,Sections 25505,75577 and 25534.1 .{.as
un a tend that if the building not currently have a tenant,that Rh my NEW RESIDENTIAL MECH, SQ.FT. City.afCBpBrb.Oof
res Ilityl notlfytheoc At of tha, q.i.mr .which 7sibe
Frio t uan aif to fOttupanry.
�`, f
ori .gen Date �A-I VlU/�L
TOTAL: ISSUED DY: l 1.
OFFICE COPY