21478 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Preis Identification PERMIT NO.
Building Ad--dttm^ss: CCfLIe_. - 21478
nee amc: n APhone:
I"`6oC�L a S$-- 1 750 CITY OF CUPERTINO-BUILDING DIVISION
C tractor's Name: Lk.Nee APPLICATION I PERMIT
�G
�4' BUILDINGELFCTRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL
AreMte /Engineer. Lic.No:
'QTY ELECTRICPERMIT .., FEE BUILDING PERMIT INFO
Address: 1059 L) S. D-Anz< 1610CL- (f�
PERMIT ISSUANCE ❑LICE ❑
e=th SED CONTR under r DECLARATION
I herebyyofn AIR30tlemlicensed underprovWonsofCMapter9(le,and c- APPLIANCES-RESIDENTIAL JOB DESCRE'T N
inense Is In
Section force and
tdcitedn3 ofthe Buslnessand Ro/eaeloneCode,and my
license Cie. l force and cited. PANELS
License Clan Lin M
Date Contractor
ARCHITECTS DECLARATION 701-IODO AMPS
ce0 7 1 understand my plata shall be used as public records. OVER IODO AMTS SQ.FT.FLOOR AREA S/SQ.FT.
OCC
`j Licensed Professional SIGNSELECTRICAL
6 w OWNER-BUILDER DECLARATION
(-n] SPECIAL CIRCUIT/MISC
7t"' ohereby ason.(Secthat
on731.5,B(ro Bushe iness
Proufctiong icenseCadc;LawAny fort he
Q fourty hick requires
parnotincustruct and Professions Code:Any city or
Fm q .oystm mpM1 orltoift rMce,a urequi theapmvntfor3leh, er ttr TFMP'MEfER ORIOLE IN D B N
YmY any structure statement
that he he licensed
pummar to the provisions
of t e i't
H6 flocasigned statement thatMtlicensedpursuant it the ofthe (OWER DEVICES _
EI Joe 3 oft the
goatee.icense Law Protractors
sCode) nnng els Section 7000)of andivl� SWIMMING IDOL ELECIW
��OS sion3ofthe Business and lsrotcssloru Code)ortM1at Mels exemptlherefromand � F, TALLI LION
< the basis for the alleged exemption. Any ,violation of Section 71313 by any OIITLETSSWITCHFSFI ES Pl S
applicant tor.permit subjedsthe apphcant to a nvll penally of nm more tMn FIAT
R2 five hundred delta.(MO).
I,as owner of the ro NEW RESIDENTIALELECTR SQ.FC. STORIES TYPECON91RXTIOR
�. ...n p mrl ya or my employees with wages as there sok
com(Sec.7 structers Code:
not intended o License Law
C. O sale nota apply
tuan m.owner f property Code:The C ntractoesimproves heneon Law
does 555�y.. whodotsuch roan ownerotpropertywho
nemporars,prvided t oryand
FS^ who docseuchwork himseBorthrough hlsownemplayees,provldedlhatsuch OCC.GROUP RFS.UNITS
improvements are not intended oroffered for sale.If,howevep thebuilding at TOTAL:
Improvement e,sold within oneyearofcompletim,the owner-builder will have
t1iLtlurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT, FEE FTOOD PONE APN
Lf L as owner of the property,am exclusively contracting with licensed PEAR ISSUANCE .
contractors to construct the project(Sen 7044 Business and Professions Code: seaga
The Cont nctoes License taw does nor apply to an owner of property who ALTER-DRAIN&VFM-WATER[FA)
Wilds or Improves thereon,and who contracts for such p(ojecra with a
onctor(a)Iicevad pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
-
151 am exempt under Sec, B&P C for the,reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEI'C
WORKMAN COMPENSATION DECLARATION 'O 'D(TURESPER TRAP -775 SCHOOL TAX Y N
❑1 hereby affirm that I have a Imurm a of aconsentudift to pytheure,ora RECEIPT N
certifirab o(Worken'ComperuaOonlwunnaora certltled copythereo((Sec. GAS EA.SYSTEM-1 INC.I OUTLETS PARKFEE Y N
3800 Lab C.)
Policy tl RECEIPTp
CGAS EA.SYSTM-OVER d(EA) BUILDING DIV
ISION FIGS
ertlied copyhereby burnished.
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE
�Certified copy b filed with the city Inspection division.
CERTIFICATEOF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200PT. Date RCCCI t1f
(CMssection need not be compined If the pemdt Vlororic hundred dollars
(S100)orlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
thatln the person inannce tmarearhe work so as to become
eemdtct is to the —
I shall not employ any person in any manner so u to become subject to Ne WATER SYSTEM/.CREATING
Workers'Compenutlon laws of California.Date PAID
C• Z Applicant NEW RESIDENTIAL PLMR. SQ.IT. Date Remi t#
Z 0 NOTICE TO APPLICANT:If,after naming this Certificate of Exemption,you
Hshould bemrnesubjet to the Workers'Compe..tionprovbloruolthe Labor TOTAL:
cN Code,you must forthwith comply with such powleloru orthis permit shall be BUILDING
III j deemed revoked.
FEE
CL s CONSTRUCTION LENDING AGENCY SEISMIC FEE
M IhercbyafBrre that there is a construction lending agency for the perform, ELECTRIC FEE
Z once ofthe work for which this permit blsseed(See.3097,CN.C.)
U Lender'.Name PLUMBING FEE
IL I— Lenders Addross QTY. MECHANICAL PERMIT FEEMECHANICAL FEE
O W Icertl/ythal l have read the,appllcadouand statethat the above Information
Is correct.I a gree to comply with all city and county ordinances and erste laws PERMIT ISSUANCE FEES PAID:
>. W relating to building comrructlon,and hereby authorise representaaves of this
(_ Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date ReCel t#
V — (We)agree to save,Indemntfy an d armiess the City of Cupertino P
against llabllitles,ju me ts,cos[ean e s hich may In anywayeames AIR HANDLING UNIT(TO 70,ODO CFM) SUBTOTAL:
against said Ci con a cin thio pennlL AIR HANDLING UNIT(OVER Ig0(KJ CONSTRUCTION TAX
r�1p^ CONSTRUCTION TAX PAID:
tna o(Appllcant/C t Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fdwm building occu pant store or hand le hazardous HEATING UNIT(TO 100,10)BTU) _ Dale RC'CCI N
restedal as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Cade Sedion 2S533(a)7 HEATING UNIT(OVER 100,000 BTU) TOT
`ln Ylltea Q No
heapplleanr orfuture building occupant use epulperent ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air arromorunts as defined by the Bay Area Air
Quality Ma mgement DistrJ07 BOILER-COMP OH•OR 100,000 BTU) pn Lt a gxr
4 Yen M No YY NI W
M1avc read the Aria nus materials requirements u refer Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Ca llfomla Health&Safety Code,Sen Ions 25505,25533 and 25534.1 Rs.r� � r ��w
understand that if the W tiding does not ou rrently have a tenant b that it my NEW SM DENTIAL MECH. JUN 94
empenslbility to notify the occupant of the requircments which most be met
prior to Issuance M a Certificate of O vpancy. C)lY Ur V
UY HII'�
Owner,or.whodznd agent Data ISSUED BY;
TOTAL:
OFFICE COPY