19786 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro+ed Identification PERMIT NO.
B.tdingAddreta 19786
,! O vO s� n
merName: PHone .
CITY OF CUPERTINO-BUILDING DIVISION
c ct r'sName: LIc.Na APPLICATION / PERMIT ba
-3 BUILDING-ELFCTMCAT.PLUMBINGMECHAMCAL CATEGORY CONTROL
Archil /Engineer. Lk.Na
/�/ QTY ELECTRIC PERMIT FEE .BUILDING PER IT INFO
V
Address: 7$ g' , PERMITISSUANCE �t%BOO D
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter 9(comment, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith5 aien7000)of DiAsion3ofthe Buslnmand PromasonsCode,and my /
Bcema is in fullf ree d affect PANELS
Llren Clam - Lir.M��� l o
Date Contndor • Y' UP TO 2DOAMPq
ARCHITECTS DECLARATION 201-I000 AMPS
�V I understand my plans shall be used as public records. OVER 1000 AMPS r SQ.FT.FLOOR ARRA 8/SQ.FT.
O
��{{ Licensed Profeal.rnl SIGNSELECTRICAL
�<� OWNER-BUILDER DECLARATION SPECIALCIItCU1T/M
7W, IherebyalRrmthm lamexempl from the Contractor b License law for the
IP
O
(°Bowing reason.(Sedion 70315,Businessand Pro(eaions Code:Any city or TEdP.MMU OR POLE INST.
C� countywhkh rcqulreaa pemdt tomwtmd,alter improve,demolish,orrepalr
AV
anystructure prlort°Its Issuance,also mquimstheappllmnt forsuch permit to POWER DEVICES
file a signed atatement that he is licensed pursuant to the provlslom of the
3 p In Contractor's License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECCRIC
sion3 of the Business and Professions Code)orthat he is exempt therefromand VALUATION
Sn S the basis for the alleged exemption. Any violation of Section 7031.5 by any
< applicant fora permit subjects the applicant to a civil penalty of nd mU77•E
ore than XfURIS O
five hundred dollaa(8SM. NEW REEDEN77AL ELECTR
�I,as owner of the property,or my employees with wages as their sole SQ'FT' STORIES TYPE CONSTRUCTION
�7a compensation,wllldothe work and the struRureis not intended or offered for
i I) sale(Sec.7094,Buslnassand Profeedon.Code:The Contractor's Lirense Law
does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP 1475,UNITS
0.0. who does such work himself or through his own employees,provided that such
Improvements are not intended or offered for sale.If,hmvever,the building or TOTAL CO
Improvement issold withinoneyearofcompldiogthe owner-bullderwillhave
Uel, olar°f proving that he did not build orlmprove for purposeofak.). QTY, PLUMBING PERMIT FEE FUOODZONE APN
Lf L as owner of the property,am exclusively contracting with Ilmosed
contractors to construct the prejact(See.7094,Business and Professions,Code: PEiMITI.SSUANCE .
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA) _
Wilds or Improves thereon, and who coeuradW for such projects with a
co6ador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LI I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINSFLOOR ROOF,AREA,ODND. SANITARY Y N
Owner Date =
RECEIPTN
WORK MAN COMPENSATION DECLARATION FDOURES PER TRAP SCHOOL TAX Y N
01 hereby affirm that T have o Im nate of consent d pythemof or RECEIPT N
3800,motif1ceteofWarken'Comperuatlon inseams ora cenllkd copythereo((Sec. GAS EA.SYSTEM-1 INC,4 OUTLET'S PARK FEE Y_ N
Policy
lab CJ
Policy# GAS EA.SYSTEM-OVER 4(EA) RECEIPT p
Com any tlU1LDING DI VISION Fr.ES
arilfied copy 6 filed hereby
the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�C milled copy is flied with the Illy W pecHon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
(Thissedion need not becompleled lithe permit isformw hundred doll.. SEWER-SANITARY-STORM EA.200PT. Date Receipt#
($10D)Icomlca.) WATER HEATER W/VENT./ELECTR ENERGY FEE Y' N
Icenot that employ
the person
eny he manner so which a tobehispermit I.subjec heard,tthe
I Whale not employ any person in any manner n ae to become subject to the WATER SYSTEM/TREATING
Workers'CompensationCompetlon laws of California.Data PAID
Z Applicant
ZO NOTICE TO APPLICANT:Ilaaerms king thisCerificam.4Eacnption,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recel tit
Hshould become subpct to the Workers'Compensation provisions of the Labor TOTAL:
CC y Code,you most forthwith comply with such provisions or this permit shall be
] deemed revoked. UILDING FEE
aC CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there is a construction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit Is issued(Sec.3097,Civ,C.) TOTAL: -OO
U O Iander'sN.we PLUMBING FEE
IL H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO lcoolly that l have read thisappliceiionand-'and the above Information
(L Is MMd.I agree to comply with a 11 city and munty ordinances and slate laws PERMITISSUANCE FEES PAID:
relating to buildingmmtro and hereby authorize representatives of this
HZ city to enter upon the ebo me and
property for inspection purposes. ALTERORADDTOMECH.
(FV or to.ave,i e (y an d keep harmless the City of Cupertino Date Receiptil
V a at a Illtlos,' ve nm oosand expenses which may In anywayacerus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
acre( dCB .con once o(the granting of this permit.
Z� AIR HANDLING UNIT(OVER FLMCM. ) CONSTRUCTION TAX
.614 nature of Applicant/Contractor Dain EXHAUSTHOOD(W/DUCI) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE- _
Will the applicant orfuture building occupant store or handle hazardous HEATING UNH(TO 100,000 BTU) Date Recei IM
material as deft nM by the Cupertino Municipal Code,Chapter 9.12,and the -
Ilealthand Safety Code Section25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' •(�
T7 Yet M Na
Wdltheapplicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$SD�I�J�E DATE
whkhemti haz.rdou.L
ntsasde0ned bythe B.y Area Air - rAsf11u
Quality Marugemont BOILER-COMP OFN OR 100,000 BTU)
4 Yes
have read the hazSe requirements 2555,2553 and 255 r.1 of MOILER-COMP(OVk72100,000 BTU) FEB 2
the o la Heal[h k Si
,Sedlone 75505,25533 and 25534.I
and tan that! enotcurrentlyhave.lenanq that it is my NEW RESIDENTIAL MECH. SQ.FT. - py4,,.�
r "Ib Ity to otifyo(the rcquircmentswhlch mustberret C Fa Of CROP.4'[IO
p or to oars ofaCauhereq I .1�!
roraulhorlud agentDate cl� LL
TOTAL: ISSUED
OFFICE COPY