23298 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build log Address: n n Q
�_ I A11;Y Lam- G J/Nl
senses one: p -
Sl�,ll�¢S CITY OF CUPERTINO�BUILDINGDIVISION .Z
Con
trad 'sI`a IAI� Ue.No: APPLICATION / PERMIT
BUILDING-M FCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL M
t� Architect/Engleee,.. Lic.No:
r QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: I'ERhOTISSUANCE ❑ 1:1 El
CONTRACTOR'S DECLARATION
I herebyaffbmt
hat lamllcmsed under provisions o(Chapter9(cnmmrnc APPLIANCESRESIDENTIAL ]OB DFSCRE'TION
Ingwith Sectian7000)of DiV sim3ofthe Businenand PmfeselonsCode,andmy
license le lnM o end effect. PANE
License C6n Lica L
Date J/(_CLS
antadar
ARCHITECT'S DECLARATION 201-1000 AMPS
q�q�vv reO Zp l understand my plareshollbe used as public records. OVER1000AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
k (/ Licensed Professional SIGNS ELECTRICAL
�¢La OWNER-BUILDER DECLARATION SPECIALCIRCUT/MISC
7Ha7, I hereby affirm that l am exempt from the Contractor's License Law for the
vl pp following reason.(Section 70115,Business and Profenlons Code:Any city or
county which requires a permit bconstruct alter,Improve,demolish,or repair TEMP.METER OR POLE INS(.
�M .''c anystmemen priced,its isasance,alsorequlresthe applicant fmsuch permitto
yK (� file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
3r, Contrador's License lawChapter mmmendngwuhSt17000) fDii
eeonav-
1n tI( SWI MMING POOL ELECTRIC
SOS alon3ofthe Business and ProfenicmCode)orthat he lnexempt therefromand VALUATION
the basisfar the alleged exemption. Any violation of Sedion 70715 hl'any OUTLETS-SWITCHES FIXHIRF_S
0$ applicant fora permit subjeebtheapplIcant to a civil penalty of not rrore than
five hundred do11am($50Q. NEW RESIDENTIAL ELECTR SQkT. STORIES TYPE CONSTRUCTION
C 7 6n I,as owner of the property,or my employees with wages as their sole
mpomatlon,will do the work and the structure isnot Intended or offered for
$ O
sale(Sec.7064,Business and Profenlons Code:The Contractor's License Law
3� does not apply to an owner of property who bullds or Improves t hereon,and
who doessuch work himself orthrough his own employees,provided that such I OCC.GROUP RFS,UNITS
Improvements are not intended oroffered for>aie.If,however,the building or TOTAL:
Improvement Is sold within one yearofcompletion,the oweenbullderwlll have
t"mlen of proving that he did not build or improve for purpose cleats.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LI L as owner of the property,am exclusively contracting with licensed
mntracton to construct the project(Sec.7014,Bush.and Profeelom Code: PERMIT ISSUANCE
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(FA)
Wilds or Improves theren
on,and who camds for such p ajeets with a
c L�
gym
ectm(s)licensed pursuant to the Contmam's Licee Law. BAER FLOW['BOTFLY.DEVICE FEE SUMMARY
1 am exempt under See. B k P C for this mason
/'., d"kh Owner Date DRAINS Fl.00R ROOF, GOND. SANITARYRECEBTp
WORKMAN COMPENSATION DECLARATION
a pI hereby affirm that I have a certificate of consent to selfdmum r a FIXTURES'PER TRAP SCI1l30L TAX Y N
Jy certificate ofWorken'Compemsdonlesurance me certified copy thereof(Sec. GAS FA.SYSTFAt-1 INCA OUTLETS PARKFEE YEC�M
3800IAb CJ
•�,'-; ,
Polity it 1AJd9b RECEIPT N
CAS EA.SYSTEM-OVER 4(EA)
Co��mppaed Cf BUILDING DIV]SION FEES
I yCertifled copy b hembyth(h city
GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertlBed ropy V(Ilea with the dty inspection dlvidm.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.20017r. Date Recel tN
(Thissection need not becompleted Bits permit V(atone hundred dollen
($700)aIceifythrtifyth WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
at In the pedm
ounre,(the wmkf,rwhlch this permit le issued,
1 shall not employ my person In any mmoaer at n to become objet to the
Workcn'Campensation laws of California. Date WATERSYSTEM/TREATING PAID
O Z Appllanl NEW RES DENT AL LMB.�QFf. Date Rece1 tN
Z O NOTICETO APPLICANT.If,after making this CertBicateof Exemption,you
should become subjed to the Workers'Compemation provision of the Labor TOTAL:
CC W Cod,you me at forthwith camply witheuch proviimamthb perrrdtahall be -BUILDING
W Cm
dmed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a mmtmdion lending agency for the Perform, ELECTRIC FEE
O Ia
Z Leceofthework forwhlchthle permit is Issued(Sec.3097,CIv.C.) TOTAL:
O oder's Name PLUMBINGFEE
LL Lender's Addmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lomityth ve dthisapphationandgatethattheaboveinforrmtion _�
1 bcorted. gyre t,c ply with elldty andca ntyordinanmsandstatelaws PERMIT ISSUANCE FEES PAID:
N reJaling building mimdion,nndhereby horlurepreaentativesafthis
Z dlyk, terupon above-mention far Inspection purposes. ALTFRORADDTOMECH.
— (We a e t uve,Inde fy a d kc erMea the City of Cupertino Date Recei t#
agalustI b i 'ju este end a seewhichmayinonywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sal In ne nce t ting fthispermit.
AIR HANDLING UM'r(OVER 10,000 CIM) CONSTRUCTION TAX
It
SlgmtuofApplHAZA DOUS r Date E(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CM 100,000 BTU) Date Reeel tic
material as defined by the Cupertl no Mu nidpal Code,Chapter 9.17,and the
I ealth and Safety Cod r Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT �
RYes . No
ill the applicant or tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESIO) ISSUANCE DATE
s whichemit hazardous air centamlmnbss defined bythe Bay Area Air Q�
^) Quality Management Distrid7 BOILER-COMP DHP OR 100,000 BTU) PAID
I�Yes Q No
havereaddhshua ouamnedals requirements under Chapter 6.95 of BOMER-COMP(OVER 100,000 BTU) p�� �� qn
Y the Glt.ornieat Ifth hufidity Code,Sed lomntly hve.tond75536.I �` Is7(Iz ^
the alianddlutlflhe Safet gdoes not Sea Ions 25505,25533 and 255that itbmy NEW REST DLNTIAL MECH. BQ.RT. 199
mpomibility to notify the occupant of the requirements which must be met /�
pd.,to Issue nee of a Cerlmate ofOaupanry. - CITY UP %dul'tH l use
Owner or authonmd agent Data ��
ISSUED BY:
OFFICE COPY