20444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject Identification PERMIT NO.
Bjl�i xxPi4M .o .1-wue 20444
wners me: 257. hone: p
W� K906((�
-� E tZ( Zd 0 CITY OF CUPERTINO-BUILDING DIVISION
Co^ntr�ad�ols Name: l. . I - Lic.N. APPLICATION I PERMIT S�2a
r..+� �hdt 12-INO Vie"II BUILDING-ELECTRICAL PLUMBING- CATEGORY CONTROL
Architect/Englecer. Ge No: MECFIAMCAL
+a♦/,, h QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address, / / , PERMITISSUANCE El ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby effirmthat lam lkmsed underprovlmone olChapter9(mmmmc APPLIANCESFESIDENIAL JOB DESCRIPTION
ingwith Se ion7000)ofDlvislon3oflhe Buslmuand ProfeasioraCode,and my
Ike..is In full farce and cited. PANELS f9�� � Gam(
LlcenseClass LILY G` 1I
Date Contractor
ARCHITECT'S DECLARATION 201-IODOAMIS
0Wl understand my plans shall be used as public records. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
U�j Lksmed Professional SIGNSELECTRICAL
6Ff'go OWNER-BUILDER DECLARATION grECIAL CIItCNT/MISC
2 s,Tidy I herebyaffirm that am exempt(romthe Contractor's License Law for the
o ❑ following reason.eiactlan 70315,B ala..rdl Professions Code:Any city or
CZI"� contywhich requires.peitmmt
t. rud,allertraprove,denolbh,orrepair TQAP.M
urmETQ(ORPOLEINST.
anystructure pal its lssuance,ab,acquires theapplicant forsuch permitto
file a signed statement that he is Ilmneed pursuant to the Provisions of the POWER DEVICES
Ou, Contraciole License Law(Chapter 9(mmmencleg with Section 7000)of Divi- t
F,�OS SWIMMING POOL ELECTRIC
RIC
on3o(the Buslnessand ProfessionaCode)orthat hebeaempttherefromand VALUAn]1Q
6 the WIC,for the alleged exemption. Any violation of SMion 70315 by any fJ OO
OUTLETSFSES
SWI7CHF7%TUR , 'q
applicantfora permlbubjeMtheapplicanl has civil pensllyofnat morethan .+'� Sw�l
Ove undrecidollarseiM. NEW RESIDENTIAL ELECTR_SQ, v S177W[S TYPE CONSIRI1Cf10N
..�r �I,as owner of the property,or my employees with wages as their sole
t mmpc..allon,wllldothe work d0themacture bnotinmaded or offered far y; '3 s �\
Cl sale(Sec.7094,Business and Professions Code:The Contractor's License law
does not apply tom owner of property who Wilds or Improves thereon,and \ OCC.CROUP RES.UNITS
whodoessuchworkhimselforlhr ghhlsownempleyees,pmvldedthatwch
Improvements are net Intended orofkred forsale.If,however,thebullding or 1'` 'ZTOTAL: s f
Improvement heold withlnomyearofcompldlogtheowaer-bu0derw1)1 have
t
an of proving that he did net build or Improve for purpose of sale.). QTY. PLUMBING PERIIVIIT FEE: FLOOD 7DNE APN
as owner o!the property,am exclusively mnlracting with licensed PFR
MIT ISSUANCE :"
atractam to construct the project(Sec.AA4,Business a ad Professions Cade: a d
Caatndor's License law don not apply to m owner of property who ALTER-DRAIN&VFNf-WATER(EA) �T
Wilds or Improvescontracts thereon, and who contrafor such p(ojects with a .1
rgR�actor(s)licensed pursuant tothe Comradah License Law. - FEE SUMMARY
LJ I am exempt under Sec. B&P C far this maven BACK FLOW PRO'T'ECT.DEVICE OUTSIDE FEES
Owner DRAINS Ff-OOR'ROOF,AREA,'COND. SANITARY Y N
j Date _ a RECEPTY
WORKMAN COMPENSATION DECLARATION FIXTIJRFS PER TRAP SCHOOL TAX Y N
❑I herchy affirm that I have a cert10rn of consent to spytheum,ora SECI=Y
cert)0rateofWorkers'CompemabonlNunna oracertified copythereof(Sec. GAS RA. IINC40 SES
3800,Lab CJ Si m- PARK FFR Y_ N
Policy Y RECGAS EA.SYSTEM-OVER 4(FA) DING DI x
Cam any BUILDING DIVISION FEES
CertlRed copy 1.herebyfurnished.thehM. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECKFEE
Certified copy b(fled with the city inspection division.
CERTIFICATE.OF I](L'MP"ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION SEWER.SAINITARY-STORM EA 2DOT Date Recel t#
(Thissedlon need rat et be
W completed tithe pertNt b!Drone hundred dollar
($100)orfeuJ WATER HEATER W/VENC/EI.ECTR ENERGYFEE Y N
Ill net thinemploy
o the performance ny m work for which ca penult is booed,
I.hall n' employ any Peron in any manner at n to become subjM to the WATER SYSTEM/TREATING
Workcr%Compenutbn Gwe o(Gllfornla.Date PAID
O Z Applicant NEW RESIDENTIAL PCMB. SQ.FL Date Race] tic
Z O NOTICE TO APPLICANT:If,after naking this Certificate of Exemption,you
should bemme subject to the Workers'Comperum ion pmvWaa of the Labor TOTAL:
N Code,you moat forthwith comply wlthauch pmvblmu orthb permit&hall be
> deemed revoked. BUILDING W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
a Ihercby afOrmthat them b a construction leading agency for the perform ELECTRIC FEE
Z arm ofthe work which this permit is Issued(See,3097,Civ.Q TOTAL:
00 Iendee.Name PLUMBING FEE
U. F Lander'.Adderae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythat l have readthis applkstionam matethat theabove Information
1 Is correct.I dgme to comply with all city aM county ordinances and mate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building mnstacdon,.nd herebyauthortm representatives ofthb
F Z city to enter upon the above-mentinnd property for inspection purposes. ALTER OR ADD TO MECH.
— (We)agree to save,Indemnify cur d keep harmless the City of Cu pert Ino Date Receipt#
agauxtlIs ties,wdg nus,nems and noes wh le],nuy lnmywayoccme AIR I IANDLINC UNIT(TO 10,000 CFM) SUBTOTAL:
ag net e 1 City In e ce o nting of t Permit.
s _z1 AIRHANDUNG UNIT(OVER 10,000CF11) CONSTRUCTION TAX
g reof Applicant/ irractor Date EKHAUSTHOOD(W/DUC'p CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant orfuture building occupant more orhandle hannlous HEATING UNIT(TO 100,000 BTU) j)a _ _ Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Tkabh and Safety Coda Section 25532(a)1 HEATING UNIT(OVER 100,000 BTU) ""� TOTAL:
_1 Na
1 the appllmni
ts, Wrebulldingo pantueeequipmentardevlceslces VENIIATION FAN(SINGLE RESID) I IH�- O JSSYA IW DATE
which emit hamrdous air contaminants as defired by the Bay Area Air civ
.lily Management Dlstrld7 BOILER-COMP UHPOR 100,0N BTU)
Yes No - -
havenadtheh. o mmerlalsrequ1mmenhunderChapter6.95of BORER-COMP(OVER 100,000 BTU) gib-1 PAJ Gunerino
the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the ratio Lmrrenls which most be met
prior to Issuance of a Certificateof Ocnrpamy.
Owner or authorised agent - Date �"�"0...1`(Ja1xSLi
TOTAL: ISSUED BY:
OFFICE COPY