19922 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B.1klmg Adders.: _ -
eleT 19922
Lnere, arse: Phone:
��/J-'''J�f'�•1'�']� 5 OSS CITY OF CUPERTINO-BUILDING DIVISION
c°"aeon a or'eName: Lm.No: APPLICATION / PERMIT ^ -0- 0
D SG PL 'BUfLDINGELECTRICALPLUMBING-MECILANICAL CATTS-ARY - CONTROLS
Architect/Engineer. Lie.No:
'QTY t� 'ELECTRIC PERMIT "FEE [BUILDING PERMIT'INFO
o '
Addreos: s PERMITISSUANCEi f� ❑
LICENSED CONTRACTOR'S DECLARATION - LJ
I hereby affimthat I am licensed under provisions of Chapter9(commenc- APPUANCESRESIDENTIAL - I JOB DESCKB'TION
Ingwlth Sectmr7eW1of Divlslon3 olthe Buslnessand Profeas ns Code,andmy '
license l (orceand effect ' PANUS .
License Chus Class Lica - -
Date Contractor
ARCHITECT'S DECLARATION -211-1000AMPS -
fx]- I understand my plans shall be used as public rvnnls. OVFRIOOOAMPS\ SQ.FT.FLOOR AREA S/SQ.FT.
00.
z�j Licensed Profeasional - SIGNS ELFFCTRICAL
6�" OWNER-BUILDER DECLARATION SPECIALCIRC / Y
Ihereby affirm that l am exempt from the Contractor's license Law for the
q following mason.(Section 7011.5,Business and Professions Code:An cit or
qq \ .atM
F I'�y countywhichrequiresaper dommtmd,alter.impmve,dennlbh,orrepair P.M POLE INST. ,
`'q 7¢ anystructure peter to Be agence,alsomq.i.theappllcant fm,sarh permit to �"'I'
rNL U file a signed statement that he b licensed pursuant to the provisions of the WER DEVI
CRU Contractors License Law(Chapter9(comci
menng with Section 7000)of Dtvl- .. .1110 xn s
30 slon3 of the Business and Professlora Code)crthat he is exempttherefromand MING POOLELECTRIC _ VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any " >tis v✓'+ �' h �A^�G•
applicant fora permit subjectsthe applicant to a civil penalty of cad more than EIFSWITCHvs IgXIgES
tq; (iyel,as owner of
pr). RESIDENTIAL ELEC osPBQ.FT, STORIES 7' MCONSTRUCTION
R° 6R'c I,act owner of the property,or my employees with wages as their sole
mpensation,wWdothew.ak,.cd thestrocture Is not Intended or offered for
5 0ulu(Sec.7014 Business and Profession Cade:The Contractor's License Law V
' $ does not apply to an owner of property who builds or Improves thereon,and I
who doessuchworkhlmselforth.gh hisown employees,provided that®ch OCC.GROUP RIS.UNITS,
Improvements are not Intended oroffered for sale.If,however thebuilding or TOTAL:
provementlesoldwithinoneyearofcompletlon,theowner-builderwlll have
Xeden of proving that he did not build or improve for purpose of sale.). Qi`Y. i,. PLUMBINGP &MIT ' t �' rEEt" FIADD ZONE. APN
L as owner of the peopeny,am exclusively contracting with licensed o✓•1
ctors to constructct the project(Sec.7044,Business and Professions PERMIT ISSUANCE Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) -
builds or Improve thereon, and who contracts for sucti p(a)ects with a
offactor(a)Bernard pursuant to the Contractor's License Law. - `, FEE SUMMARY
1=1 am exempt under Sec. B&P C for this reason BACK FLAW PROTECT.DEVICE
Owner Data DRAINSFLOORROOF,AREA,COND. SANITARY Y N
RECEIPT M
/ WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP • SCHOOLTAX Y N
❑f hereby alarm that I have'. lmumne of consent to opytnersi ora RECEIPT M
mNflab ofWorkers'Compevatlonlnauranceoramrtl(led ropythereof(5ec. / GAS EA SYSTFMI INCA � PARK FEE Y N
Pol3800,his C.) I a
Com N RECGAS F.A.SYSTEM-OVER 4(FA) DING DI'p
a"y BUILDING DIVISION FRES
Certified copy b hereby th the city GREASE/INDUSTRL WASTE INTERCEPTOR - PLANC14ECK FEE
Certified ropy I,filed with the city Inspection division:, ,
CERTIFICATE OF EXEMPTION FRO MWORKERS' GRFASETRAP PAID
Cos PATIONINSURANCE SEWFR.SANITARY-STORM EA.200FT. - Date RCCCi t#
(TMs section need nos be com compiMed If tM permit is(or one hundred tlollem
(41 I0)orfm3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
[certify thatoy an perf on nce inan thewoek for whic,to become
permit issublec booed,
I shall rV employ any person In any manner at as to bcceme wbject to the WATER SYSTEM/TREATING
Workera'Compensation laws of California. Date - PAID -
O Z Applicant -
_Z O NOTICE TO APPLICANT:[(after king this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQb7, Date Recei t#
~
should became sub)ect to the Workers'Compensation provisions of the Labor TOTAL:W Code,you must forthwith comply withsuch provisions orthb permit shall be »•�
'W > domed revoked.
d C CONSTRUCTION LENDING AGENCY BUILDING FEESEISMIC PEE a -a
I hereby afirrnthat there h a romtruction lending agency for the perfornF TOTAL: ELECTRIC FEE
O once of the warkforwhich this permitls issued(Sec.3097,CIv.CJ
(� Lender's Nafre_ _.A./OCL - 1 , PLUMBING FEE
LL ~ Lenders Atldress_ - QTY. , MECHANICAL'PERMIT , 'FEE. MECHANICAL FEE
O W ImrtBythmlhav<readthbappliratlonand otatethattheabovelnformitlon
d Is correct.l agree to comply with all cityand county ordinances and state laws PERMTTISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives ofthis
rity to entero caths above-mentioned property for inspection purposes. ALTERORADDTOMECH.
V — (We)a save,Indemnify an d keep harmless the City of Cup,nle. - Date Receipt#
agaimtlla lit. ,NdRr' ate d 1preseswhichmsyinanywayaceme AIR HANDLING UNIT(TO 10,000CFM)- SUBTOTAL:
aga Wt.1 yin cons t e t a sting of this permit.
Zd� AIRHANDL4NG UNIT(OVER H ffl0CEM) CONSTRUCTION TAX
Signature of Ap cant/Contractor ID,ta EKHAIIs'r HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant°rfutum building occupant store orhandle hazardobs' HEATING UNIT(TO 100,000 BN) Date ReCei t#
materUl as defined by the Cupertino M.Mdp.l Code,Chapter 9.18,and the -
Heahhand Safety Cod"71e��_SIection 25532(.)1 HEATING UNIT(OVER tail"BTU) OTAL: . 7L
❑ Yes bM No
ma
—TOTAL:
the'applirant mrc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) CE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3IE'OR 100,000 BT[n
4
Yen
��}}��o
haveread the alth&k�ta matertabrequirementsundee Chapter 4. I of BOILER-COMP(OV IR 100,000 BTU[
the
erataneniallifthebSafetyCode,Satlora 75505,25533 and 25534. 1
understan at ltthebuildin doesnotcuerenllyhave a meanpthatlllsmy NEW RESIDENTIAL MECLL SQ.Fr
caporal natlfyth to he qulrcmentswhich must be met -
prior to ce of a Ce t • '• „JJ < l(,(L,IJ .n
Owner.r..thad4fidagent Dae ISSUEDBY: y�VT�as`a
TOTAL:'
OFFICE COPY