23922 APPLICANT TO FILL IN INFORMATI N WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification ! �j JO C't �•�'-7 / PERMIT NO.
Building Addie,,: - Q J�J L b - 23922
were "roes: h°ne: p
`�'/�,'�/aQ r(,l 6( yA-2(l ' CITY OF CUPERTINO-BUILDINGDIVISION �Q
C°"trad°r'aName: Lie Nee APPLICATION / PERMIT l
s ��2 2
Architect/En n BUILDINGE.ECTRICA4PLUMBING-M1:CIIAMCAL CATEGORY CONTROLM
Bi ee Lic.No:
tQTY ELECTRIC PERIvfFF '•PGE••,; .•BUILDINGPERMIT INFO.
Address: „POMTISSUANCE • .. •. �� ❑ ❑
LICENSED I a CONTRACTOR'S DECLARATION'
[hereby affirm that lamlicensed under provisions so(Chapter 9(commenc APPEANCES.RESIDEN[[AL JOB DFSCRB'f[Oi.gwlt [J1
hocreeh Sect ion imexa(Divieion3ofthe BuelnessandPro(ensloneCode,and my O �a
license Is In full(ora and effect. PANELS
License Clara Lic.p
Date Contractor UP TO 2DOANU
ARCHITECT'S DECLARATION 1201.1000AMPS
p�p�uu ae Zp I understand my plans shall be used as public records. ` OVER1000"PS- SQ.FT.FLOOR AREA §/SQ.FT.
Fi�(0 Licensed Professional SIGNSELECTRICAL -
fna OWNER-BUILDER DECLARATION SPECIALCIRCNT/MISC
7s. 7e. 1hercbyafBrm that lamcxempt from the Contractor's License Law for the
O
following reason.(Section 7031.5,Business and Professions Code:Any city or, TEMP.METER OR POLE INST.
F�
county which requires"permit,construe,esthampmvgderrwlbh,orto _ -
Y any structure prior to statement
hat he I,also rcqulrcatuant to the provisions
Ofpermit e POWEBt DEVICES
s4 a Co a signed statement that he b Ilcensed pursuant to the tion 7 ns of the
`Qj ate Con3ofthsusinseLaw(Cfesolo9(com)orthag withxemonherefof and SWMN(NG POOL ELECTRIC
f, O< sion3ofthe Businenandl'rofenlons Code)orlha[heb exemptlhercfromand VALUATION -
S"•�• the basis for the alleged exemption. Any violation of Section 70315 by anyTS
applicant fare permit subjects the applicant to a doll penalty of net morethan - OU7LETSSWITC[iFSEX7l)RES I
0 Bve hundred dollars(§500).
❑I,as owner of the property,or my employees with wages as t heir sole NEW RESIDENTIAL ELFGTR__SQRT, STORIES TYPECONSTRIICTION
L.7" compensation,will dothe work and thestrudure is rentlntended or offered(or '
SNq - sale(Sec.7044,Business and Professions Code:The Contradots License Law '
0�2 does not apply to an owner of property who builds or importers
oves thereon,and "
0. who dosuch work himself his own employees,provided that such OCC.GAOIIIRFS.UNITS
improvements arc not Intended oroffered forsale.If,however,thebullding or T i
improvement bsuld within oneyearofcompldioNtheowner-bullderwill have -
tl�e,�arden of proving that he did not build or improve for purpose of sale.). QTY, , PLUMBING PERMI"F,P•',+ ' FE& t,, FIAOU yDNE APN
n C as owner of the property,am exclusively contracting with lkenud PERMIT ISSUANCE
contractors to construct the pmjed(Sec.7016,Businessand Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve.thereon, and who contracts for such pRpieds with a
co,iB[actor(s)licensed pursuant tothe Contractor's License FEE•SUMMARY
Law.t BAIX FLOW PROTECT.DEVICE `
LJ I am exempt under Seca B&P C for this reason
Owner FEES
DRAINS FLOOR ROOF,AREA,CONU SANITARY Y NOUTSID�
., - Date RECEIIrTM
WORK MAN COMPENSATION DECLARATION pIXTURESPER TRAP SCHOOL TAX - Y N
❑1 hereby affirm that I have•certificate of consent to opytnsure,ore RECEIPT M
certificate of Worken'Compensatlonlnsurance ora certified ropythemof(Sec. GAS EA.SYSTEM-I INCA OUTLETS
3000,Lab CJ - PARKM, V_ N
Policy M RECEIPT X -
Com
any GAS FA.SYSTEM-OVEA)R 4(E .
ECertfied copy Is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR LA CFIECK FEE
BUILDING DIVISION h'EF.S
- ❑Certified copy b filed with the city Inspe<lon division,
CERTIFICATE OF EXE'M PEON FROM WOR KERS' CREASETRAP -
COMPENSATION INSURANCE
(Thlssedlonneed notbecompletedifthepermit b(oromhundredSEWER-SANITARY-STORM STORM EA.200171. + Date RCCCIpt#
($100)or less) WATERIREATr.RW/VENT/E.ECTR ENERGYFEG Y' N
(certify that In the performance I anymnnersorwhich mtobthispermltb Issued, —
I shall not employ any person In any manner at n m bocome subject to the WATER SYSTGI/TREATING .
Wwkera'Compensation lawn of California.Date - PAID
O Z NOTICApplicaE AI' NEW REEDENDAL PLMB. SQ.fT. Date RBCY'1 t#
Z O NOTICE TO PLICANT:If, her making this Certificate of Exemptbn,you
should become subjcd to the Workers'Compensation provisions of the Labor HTOTAL:fn Code, comply with such provisions orthbpermitpet shall be BUILDING '•
G
W > deemed Invoked. BUIL INGEE
CONSTRUCTION LENDING AGENCY
CL Ihereby affirm that there b a mmtrudlon lendingagenry foithe perform ELECTRIC FEB
Z aero ofthe workforwhichlhb permit b Issued(Sec.3097,C1v.C.) - TOTAL: jr�61
V O Iandw'sNa"n - - PLUMBING FEE '
QTY.
LL F lender.Address - 'MECHANICAL PERMIT •^E MECHANICAL FEE
O W Icedifythatl luvereadtM,applicationandentethattheaboveinfnnution
fL e
emend.I agree to comply with all city and county ordinancesanl state laws PERMITISSUANCE - FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
j— 2 city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTOMECH. Date RCcei
— (We)agree to save,ledemt#nlfy a"d keep harmless the City of Cupertino p
a Wt llabi@ies,Idg ts,costs and expense,which may In any way accrue Al R HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a b try In ence of the granting of th permit.
Airs HANDLING UNIT(OVER lo,moclTi) CONSTRUCTION TAX
Signature, p / ntractor Date EXHAUST HOOD(t/DUCT) - CONSTRUCTION TAX PAID:
AZARDOUS ATE AL DISCLOSURE'
Wllltheapp cantor futureb (dingo nt store or handle havardous HEATING UNIT CTO 100,000 BTU) Date ROCCI I# _
mate,rialasdef ed by t1i Cu pe Ino Muni pal Code,Chapter 9.12,and the _
iieilthand Safety Codo�++--S�ection2S532(a)2 - HEATING UNIT(OVER 100,000 BTU) TO
❑ Yea LJ No
Willemit
appliantorfuture
ontaminants oaupant use theequipmentArea Ai devices VENTILATION FAN(SINGLE RFSTD) ISSUANCE DATE
which emit havardous air contaminants as dented by the Bay Arca Air '
allly Management District? - BOILER-COMP QHPOR 100,000 BTM
Yea' M No 1�
have read the haza'3ous materlaLs requirements under Chapter6.95of BOE.ER-COMP(OVER 100,000 BTU) Y� � ' D
the California Flcahh&Safety Cade,Sections 2550.5,25533 and 75534.I
understand that lithe Wilding does net currently have a hnaaLihatltb my NEW RESIDENTIAL MECIi' SQ'�'
responsibility to not By the occupsest of the requ lremenls which most be met UULc 199
prior to issuance of a Certificate of Occvpa ncy. - - /,
Owner or authorized agent - Date CITY
01-�%;*jam„M .
.TO ISSUED BY:
OFFICE COPY