22803 APPLICANT TO FILL IN INFORMATION_ WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - _ - PERMIT NO.
BuildinglAddmse: ,C • 22803
w—n-e�'r"s"'' - � one: - -TA
I Q t , A I �I 0 CITY OF CUPERTINO6BUILDING DIVISION �O^ � •d I
Can aa.raName: y LIc.No: APPLICATION / PERMIT "`►
C o 1
" BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY C .
Amhlte,251neer. A _ Lk.No:
IMA '�. IA VL- J• i` "' - " .. BUILDING PERMIT INFO,
- QTY + ELECTRICPERMIT `' " TEE "`•
Address -7 _rt4a6tF PERMITISSUANCE ® ❑ . . .❑ ❑ ,
LICENSEDCONTRACTOR'S DECLARATION '
I Mrebyaffirmthat l am Bcemed under provislomof Chapterg(commanc, APPUANCESRESIDENTTAL
Ingwlth Sedion7000)of Don
ivisi3ofthesl BusandPmfeesionsCode,andmy
license is In full form and Wfed PANELS
License Clara I Contractor
I
Date e• as 0—�.L Contractor
ARCHITECT'SDECLARATION 7014000 AMTS
NZ I undersea nd my plans shallbe usedYas public re e. OVERT SQ.IT.FLOOR AREA
00 IAL
N
2� Licensed eav om L --� vry-v9� - � SIGNS EL C {� L ED 6 OWNER-BUILDER DECLARATION
SPFLLILCIXCUfT/ LSC
Iherebraf@mthatlamexem)rt fromtheCont Tessio LicenseLaw(m the
Youowingreason,(Section70315,Business tmdand professions Code: h, cityor
G �t�+ cauntywhlch requlresa para[ho c.orequialter, applicant
fors ch,ormtto P.MEI'ERORI+OLE INS['.
f ^a.aa any.signerepriortolbhahe Is alcensed restheat tot het romions ofdte )'OWER DEVICES OAT
O 6 U Rle a signed Ratemenl that he is IlansN pursuant to the provlslom of the '
3w{� Contractor's License Law(Chapter 9(mnmencing with Section 7000)of Divt- SWIMMING POOL ELECTRIC VAI.UA710N
BOJ sion 3 of the Businessand Profealom Code).,that he is exempt therefromand tea "
Q.•�77 the basis for the alleged exemption. Any violation of Section 7611.5 by any OUTLE7SSWITCHFSFIXEIURFSZ(A
applicant fora permit subjects the applicant to a civil penalty of net more than `+ Vft 4
five hundred dollars($500). TYIrE CONB'i'
❑I,as owner of the property,or my employees with wages as/heir sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES RUC'f10N '
s.Z^O compensation,will do the work and the structure Is not intended or offeredfor
C� n scale(Sec.7044,Business and Pmfexlow Code:The Contractors License Law
does not apply toanowner ofproperty who Wilds orimprovestherem,and OCC.GROUP RES.UNITS
FF who doessuchworkhmagiforthraugh hlaownemployees,provided that such
Improvements are nM intended oroffend formic.If,however,thebuilding or TOTAL:
Improvement lsmld within one)varofcomplmt n,tWo ner-budderwill have „ „ ,,,.„PE,
th,�urden of proving PL
that he did not build or improve for purpose of sale.). QTY, UMBING RM.. _,IT'S FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The C.meacmr'a License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER A)
W lids or Improves rherron,and who mnvam for such pt.jem with a (E
1 - mJJl1tjjactor(e)Ilmnsed pursuant to the Contractor(Licem l,.w. FEESUMMARY -
LJI am exempt under Sec. B &P C for this reason BACKFLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y _ N
OUTSI DE FEES
Owner Date RECEIPT N
'WORKMAN I have a COMPENSATION DECLARATION SCHOOL TAX Y N
Of hereaffirm lhat'1 have o certificate of consent d self- FIXTURES.I'FR TRAP RECEIPT N
3800,1 boffWorkers'Comperwh.nlmunnceoramrtBkd ropythere.f(Sec.
3800,fab C.) CAS EA.SYSTEM-1 WC.40UTLET$ PARK FELL - Y_ N
Policy N GAS EA.SYSTEM-OVER 4(EA) RECEIPT N
'Com any pU1LDING DI VISION PEE$
[�Ce td copy is hereby furnished. CREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
Cen�ed copy is flied with the dty lrupeRlon division.
P
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPAID J-64,119
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT at6 R 1 t#
RFlasection need not be completed if the permit is for one hundred dollars
($10 evnify that
WATER HEATER W/VENT/ELECTR [ENTjiC� F E YImrtify that in the perforrtunce o(the work(.rwhkh this pemdtlsluued, V` —
I shall nW employ 55nn7 person n any manner sou _ ro jeerto the WATER SYS /TREATINGWorkers'C a s#los(AaJ fCallfoml..Date °I ID
O,Z Applicant NEWRESIDENTIALPLMB. QFT. Dat MI t#
Z O NOTICE TO 'P ICANT:U.after making this Certificate of Fxcmpli.n,you
sh.ldbemme.bjldi.the Wader.''Compensation imwislomofthe Labor T fAL:
W Cade,you most forthwith comply with such provislom orthis permit shall be UILD
Uj j' deemedrevoked.' a�W
d G . CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there is a comtructlon ane ing agency for the perfornry ELECTRIC FEE
Z ante of the work for which this permit is iswed(Sec.3097,Civ.C.) TOTAL: PLUMBING PEE
(.) 2 le /
lender's Name
LL F Lamers Adams. QTY. MECHANICAL'PERMIT',( .FEE MECHANICAL FEE
U Icertilythatlhavereadthisdpplkationand stat ethattheaboveinformation
O W iscorrect.Iagreetommply with All city and county ordinances and state laws PIAMLISSUANCE FEES PAID:
} CL relining to building comt.cwni,and hereby authortae representatives of this
(—_Z city to enter upon the abovementic, ed pro Ty for impedlon purposes, ALTER OR ADDED MECH. 1
(We)agree to save, Oemnity an d kc harasses the City o!Cupertino Date R ceipt#
V against llab g cats,maaand ex sees whkh may In anywayacaue AIR HANDLING UNIT 8010,000 CFM) SUB OTAL• 1
agalret sal tyl bn core of the tin this permit.
AIR HANDLING UNIT(OVER 10,01)0 CIM) CONSTRUCTIONT X
Sig store ofA pus nor Date EXHAUST HOOD(W/DUCT) CONSTRUCTIONT PAID:
HAZARDOUS MATERIALS UISCLOSURE I ' _
Ill the applicant or future building occupant store or handle hazardous IDEATING UNIT(TO 100,"IETU) pate Rec ' t# _
more alas defined by the Cupertino Municipal Code,Chapter 9.1 Z and the
I Icalth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,"BTU) TOTA
Yes No
Will the applicant or iture Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eat hazardous air contamicams as defied by the Bay Area At, ppyy pp
Q,ra111y Management DsMci7 - BOfLGR-COMP OHPOA l00,IXq BTU) 8' N
a Ycs ALJ No
d `('have read the hazaNbus materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000BTU)
[tie California Health&Safety Code,Sections 25505,25533 and 25534.1. 1tl0y 19 1991 -
understand that iftheWI II
AL that it is my NEW RFSIDAL MECH. SQ.FI'.
reeporuibillty to notify the occupant W the requimments which most be met
prior to issuance of a Certificate of Oecupznry.
- CTI Y UF'CUpt;hi INU
Ownerorauthorixedagent Date:
WAZ
TOTAL: ISSUED BY:.
OFFICE COPY
F1ray. ppp y d/ r� - �•q0, � ' I
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