20192 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identification PERMIT NO.
Building Addmas: L4A e, .�^ � I?-1>c) ¢-c,i 20192
\� � _ A A
TE
�GV� r CITYOFCUPERTINO-BUILDING DIVISION
Contractor's Name: Lic.Nee APPLICATION / PERMIT
Architect/Engineer. Lk1. .Na—6
: BUILDING-ELECTRICALFLUMBINGMECHAMCAL CA7FCARY CONTROL#55Q /
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO o
Address: PERMITISSUANCE �'�— ❑ PLUMB MUCH
E] ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bernard under provisions o(Chapter 9(..no APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
ingwRh ScdJon7000)of Divialon3Ofthe Buetnessand ProfesslonsCode,and my
license Is In full(orae and effect. PANELS
License Clam LIC#
Date on
pyc\
Cmctor ll....JJ
ARCHITECTS DECLARATION 201-1000 AMPS
NO O I understand my plans shall be used m public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNSELECTRICAL
6g OWNER-BUILDER DECLARATION SPFCWLCIRCU[7/MISC a4
1., ; Iherebyafllrmthatlam exemLaw for the
Opt fromthe Contractors License
_Q following reason.(Section 7031S,Beat..and Professions Code:Any city or
ZSZI awntywhichmqu4 apemttommtmd,altenimpmve,demolbh,orrepalr TEMP'METER OR POLE INST.
anystroctue prior to its lesuance,alsorequlmstheappllcant forsuch perrtdtto OWER DEVICES
C O file a signed statement that h k licensed pursuant to the provision,of the
3�t' Centractora License Law(Chapter 9(commencing with Section 7000)of Divi- SWPIMING POOL ELECTRIC
SOS sion3 of the Business and ProfessionsCode)or that he k exempt them(romand VALUATION
�'•,--t the W sis for the alleged exemption. Any violation of Section 7031.5 byan r� 0 d
`or1Sn applicant for a permit subjects the applicantto a civil penalty of net morethn OUILETSSWITCHESF FIXTURES
five hundred ner a.of hepr. NEWRESIDENTIALELEC SQFr. STORIES TYPE CONSTRUCTION
'4..' ❑1,as owner of the property,or my employees with wage as thele role
compensation,will doth work and the structure Is not intended or offered for
a` O sale(Sec.7044,Businessand Proleakn,Code The Contractors License Law
p�$ does net apply to an owner of property who Wilda or improve thereon,and
whodoessuchworkMmselforthmugh hisown employees,provided that such OCC GROUP RIS.UMTS
Improvements are not intended oroffered forsale.If,however,thebullding or OTAL
improvementksoldwlthlnoneyearofcomple ioNtheowner-budderwillhve
Xeden of proving that he did not build or improve for purpose ofask.). QTy, PLUMBING PERM FEE pW5D ZONE APN
L as owner of the property,am exclusively contracting with Iindnsed X ctpERM1T ISSUANCE
cton to construe the project(Sec.7014,Business and Professlons Cade:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN Ar VENT-W
W lids or 1 proves thereon,rad wh dones for suth p(ojepa with a
cRjc Ilren n neons License Law. gpIX FLOW PAOTECT.D FEE SUMMARY
Lf I seem B k P C for th nuon
DRAINSFLOOR,ROOF,AREA,OD SANITARY Y N
Own 0 OUTSIDE I'll�9
Date -- RECEIPT P
EN ALIO OECLAR ON FIXTURES PER TRAP SCHOOL FAX Y_ N
1 hereby orf m that I have a I rt ane of condi m eIf-mpythemof ora RECEIPT M
MOD,LecKiflabo(Workere'Compen,atlOnln,uranm oracertifled mpythereof f$ec. CAS EA SYSTEM-1 INCA OUTLETS /
3800,lab CJ PARK FEE Y N_
Copilm ny _ CASEA.SYS IM9 OVER4(EA) BUILDINGEI IVISION FEES
�Certlfled copy is filed Mththecitfurnished. a GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
OCcrtkied ropy V filed�Mth the sky Inspection division. �-�I
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID" -L1—k WIN c[ o
COMPENSATION INSURANCE SEWER-SANITARY STORM EA 2MFT Date RC i t# `as�O
Rhis section need not h completed lithe permit la(wrens hundred dollen
(4100)m1caJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Imnot thatlnthe person In nce
tmannerhework for to hich
pertbjectit Is to the
1 shall not employ any person In any manner at a to become object to the �y �s
Workca'Compenatiwn Laws of Call(omla. Date WATER SYSIFM/TREATING PAID `� 'TQ I�
0 Applicant Date Reeei t# Go,00
O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFL
should bemmL subject to the WOrken'Compensation provlslors of the Labor TOTAL:
N Code,you me.,fort hwith comply with such provisions or thla perrNt shall be
j > deemed revoked. BUILDIWSUBTOTAL:
O CONSTRUCTION LENDING AGENCY SEISMI
I hereby affirmthat them kacon,wctuied(Sec. agency for the perlorm TOTA ELECTR
Z Lender the workfor which this perMtbbsued(Sec.3097,C1v.C.) u=20
O Lenders Na
PLUMB1-0,00
F Lender iAddma QTY. MECHANICAL PERMIT FEE MECHA /4/OO
]reed.I hat l five read t with a li citlan d counts ordinances
above ld gate tionlaws 25 -
-TI
S is correct.Iagrmmcomply with all city and countyoNinanres and state laws PERMR ISSUANCE p — FEES P
N relating to building construction,and hereby,authonas repecanatives ofthb /.�
• Z city m enter upon the abovcmentioned pmperty for Inspection purposes, ALTERORADDTOMECH. —L*I
— (We)agree to ave,indemnify an d keep harmtea the City of Cupertino Datipt#
against liabilities,Ndgmrnts,crst.and expends which may in any wayaccrue AIR HANDLING UNIT(TO 10,000 CFM) TAL:
against said City in conaequennd of the granting of thispermit.
AIR HANDLING UNIT(OVER tgiT)O CEI) CQNSTRUCTION TAX
Signature of Applicant/Contractor Date IXHAUS T HOOD(W/DICT) CORUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle hvarelcus HEATING UNIT(TO 100,000 BTU)
material as ed by the Cupertino Municipal Code,Chapter 9.12,and the ate Reaei t#
a and fe C ion 25537(.)7 HEATING UNIT(OVER 100,000 BTU) T AL:
No
ill thea pliant fu building occvpantux equipment or devices / VFNTIIATION FAN(SINGLE RESID) I$$[ITjdi¢gATE
Mch emirea t luvardous air contaminants as defined by the Bay AAir _
Quality Management 'tri 7 BOILER-COMPQHPOR 100,0008TU)
If+; Yea o -
I mhaz o requirements Chaptero! BOILER-COMP 100,000 BTU) ` U•I jJtfieGhlomlaHcat Code, pin 2505,25533and 25534. 1 1
underst dthatifthe u'din a cu ntlyhaveatewnt'that It is my NEWRFSIDENTIALMECH. SQFf.
rep is dayt npify ocmp f immentswhl hrZtbemet
pn t Ce f o` Cucertino
ry.
r or ager Date
TOTAL: � � 1/5911 DB
OFFICE COPY