20073 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
_
Building Project Identification PEIM TNO.
Building Address:Cao Sat' ��x,t L �� 2 O O n 3
a_T� ' Pro `Z9106 CITY OF CUPERTINO-BUILDING DIVISION A G I �(/
Contractors Name: sec.No: APPLICATION / PERMIT �_Zla_qO
NTROL
BUILDING•ELECTRICAL-PLUMBINGMECHAMCAL CATLGORY COIy�ry.v
Architect/Engine,, Llc.No: l 7 `J
QTY .ELECTRIC PER FEE
aaaa,s c—aBUILDING PERMIT INFO
Address: �lf% y� X ❑
PERMITISSUANCE VAI
ELECI
LICENSED CONTRACTOR'S DECLARATION
I hereby that licensed dr provisions ofChapterg(comancere.
APPEANCLSRE9DENTIAL JOB DESCR[P[ION
InthScit..700)olDii.ion3.fth,B.s.essandPmfsslosCode,and my
license I.enfull force and affect.
PANELS ,
Clara Lica
Date (�6G(•� 5P1�-
Date Connador UP TO 20DAhus
ARCHITECT'S DECLARATION 201-I000AMPS
,gyppp±+ O 1 understand my plantashag be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FT
Licensed Professional nal SIGNS ELECTRICA
GG 6`LCA, OWNER-BNLDER DECLARATION / 1 O
fn]3 SI'ECIALCIRCUIT/ TSC l -
}i"' Iherebyaf(IrmthatIs.exempt from the Contractor'aLkenec Lawlor the
0Mp lo0owing rcaeon.(Stolon 7011 S,Business and Professions Cade Any city or
countywhkhrequlreaaper trommtmdalter,impmve,dennllah,ormpatr TIME.MEIEROR POLE IN
7 anystrieure pdorm its Wuance,alsorequireitheappllcint for such pernatto
rNG file a signed statement that he Is licensed pursuant to the provlalom of the POWER DEVICES
O7wy Contactor.License Law(Chapter 9(commencing with Section 7000)of Owl. SWIMMING POOL E.ECIRI
BOJ sion3orthe Busenessand ProfeniomCode)orthatheisommpttherefmmand VALUATION
•77 the basis lar the alleged exemption. Any violation of Section 7011.5 by any ���_
applicant for a permit subjects the applicant to a civil pemltyofncteror,than OUTLE7""SW17'C11F_';]•TXT1111
oe drewnonan , NEW RESIDENTIAL ELECTR
QQQ s owner of theheproperty,or my employees with wages a thele dale �'�' STOIO� TYPE CONSTRUCTION
mpertaaHon,wllidothe work and thutmdure bnM intended or offered for
�•O sale(Sec.7074,Basin..and Profeselons Code:The Contractors License Law
$ dues not apply to an owner of property who builds or improves thereon,and
EE whodon suchwork himsefforthwgh hlsownemployees,provided that such OCC GROUP RFS.UNITS
improvements arc not intended orofleredfor sale.If,however,the building or TOTAL: t
improvement Is sold within one yearo(completion,the owneebuilderwlll have -
the burden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD TONE APN
U L as owner or the property,am exclusively contracting with licensed PERMIT ISSUANCE .61t
contractors to cortan
ld the project(Sec.7044,Business `M
and Professions Code:
The Contractors License law does not apply to an owner of propertywho ALTER-DRAIN k VENT-
builds or improves thereon, and who contracts for such ptujects with a / WATER(EA)
gp ,torf�)licensed pursuant to the Contractor.License Law. FEE SUMMARY
iSl I"int exempt under Sec B A,P C for this mason BACK FLOW PROTECT.DEVICE FiFfm RE FEES
Date S FLOOR, A,COND.DRAINS. ROOF,ARESANITARY Y N
Owner Lar' RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURE&PER.IRAP '•1 SCJ3OOLTAX Y N
0 hereby opera that I have o aertlBdte of consent df op thereof
ora / <x RECEIPT N
certi0daeof Warken'CompewtionlrourancewaaertlflM copythereo((Sec. GAS.EA.SYSTEM-]INCA OUTLE75 PARK FEE Y N '
3g W,
1_ Pullry# CAS EA.SYSTEMO ER7(EA) DING IIPT I
Com any - BUILDING DI VISION IT CedifiS
copy is hereby filed
the city
CREASHANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
F-1 Coddled copy V(Ikd with that d4,1mp,dlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAPpAlp`J LD 555'
INSURANCE
NSURANCE
Rto
heaslonneed not be compl TI Nmiae
pert VCordhundreddollars SEWER-SANITARY-STORM EA 200Ff Date Recei tpL(4,60
($100)orlem.) WATER FIEATFR W/VEM/ELECTR ENERGY FEE Y N
I certify that In the perlomucenof the work forwhich thea permit is i sued, —
I shall not employ any person In any manner so as to became subject to the WATER SYSITM/TREA7INC
Workers'Compensation laws of Callfornla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. Date Recei t#
Z O coNOTICETO APPLICANT:$ m
after aking tMa CertBldteor ExempO _SQ.7r,Into
should beme seb*d to the Workers'Compereation pervbia®of the Labor TOTAL:
TO Code,you must forthwith comply with such provisions or this permit shall be 131JILDING IPE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
O
d Ih4the wfllrmthat them becortatmctionla(Sec.3agency7,Civ. .) perform ELECTRIC FEE ��f1
� Z anm of/heworkfarwhkhthla permit is issued(Sec.W97,CIv.CJ TOTAL: W
V Q Lender.Name PLUMBING FEE
14, E L,ndcr.Addresa QTY. MECHANICAL PERMIT FEE MECHANICAL IEE
O W Imrti(ythatl have read thkapplicatlanand statethattheabrevelnimeranion
ismmet.loge,,tocomplywithalldtyandcountyordinanceaandmdmlaws PERMIT ISSUANCE. FEES PAID:
} 4 relating tobuliding construction,and herebyauthorlurcpresentativesofthb
H W city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnity an d keep harmless the City of Cupertino Date Receipt#
V against Nobilities,judgments,areas and exp,nses which may In any wayaccrua AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
against, City in coma nm of the granting of this permit. •
� AIRHANDLING UNIT(OVER]O,000CFM) CONSTRUCTIONTAX
ter /
Signature o(App
ilcAZAR nOUS Date EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orthe future Cupertino
gocevpan ode, handle ETFATWC UNIT(TO 100,000 BTU) Date Recei tN
material as defined by the Cupertino Municipal Cade,Chapter 9.12 and the ry�-P�a
HealthYea Safety Code Section 255111,11 HEATING UNIT(OVER iW,OW BTU) TOTAL: P7v
II''�� Yrs �tNo
ureen
which caret
cake applkantorruturc building occupant dbythe Bay equipment Area
devices VGNRLATION PAN(SINGLE RESID) ISSUANCE DATE
whkheMnaement air cotta Mnants as defined by the Bay Area Alr
Quality Management District? BOILER-COMP DIm OR 104,000 BTU) �a
Yes the hu❑❑No 1_�OWTe/
beverata Health
Safety
mrudei ls Seale 25505tsundeaChapter. 1 of BOILER-COMP(OVER IW,IXIOBN) J
the Crstuarnlaatlith building Code, otcurra25505,ve a to nd,that I 9 Isbju
undenWnd that ratifyheocc does not erequirantly hvixtsw which
thatb met NEW RESIDENTIAL MECH. SQ.IT. �" JV
. .
responsibility c ratify Cehe occopantofiherequlremnnte which must he met
prior to issuance ofd Certificate orOttvpanry. M�•
Ovencroraulhodred agent Date ISSUE YI �iljp LA-�vJ'
'TOTAL:
OFFICE COPY