21800 T ' APPLICANT TO FILL IN INFORMATION WITHIN RIE RELINES— USE BALL POINT PEN ONLY
Building Trued Identification - PERMIT NO.
Building Address: 8^� /�0 O
G
wnere ossa: onp. - -
/Y CI TY OF CUPERTINO-BUILDING DIVISION --�y�
C actnrsName . LIc.N«- APPLICATION /PERMIT
v ��'�((3� BUILDING-ELECTRICAUPLUMBING-MECHANICAL CATEGORY CONTR L«/
. hitect/Engineer" .. LU.No: G
,.B6B'GTRI¢PERMIT ' "FEE;,,. - BUILDINQa PERMITINFO '
Address" C�� q $ PERMITISSUANCE- �B ❑ ❑
prMIR MECH
LICENSED CONTRALTO SUECLARATION
[hereby ef(Irm thatlam licensed under provisions of Chapter9(commrnc APPLIANCESRESIDEMIAL / JOB DESCRB'TION
IngwithSeMan7000)ofDiv-1°n3o(the Buslnessand Pro(easloneCode,and my /�lA3
license is In hill force effect. PANELS / r
LcenseC �Tl
LIc.« )--
Date Contractor r . S,�'f'S � L
L ?RCHITECTSUECLARATION 201-1 flIXIAMPS �iJS
gypp�±±!!IXO O I understand my plans shall be used as public records. OVER 1000 AMPS - SQ.FT"FLOOR AREA S/SQ,FT.
E 19 Licensed Professional - - SIGNS ELECTRICAL -
G�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC -
Ihercbyafflren that lotmexempt from the Contractors License law for the
following reason.(Section 7(31.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST. - -
I ysty whichcture requlrees permitissuance,
toconstmuirestheact,alter, provgdemol-h,orrepair—notto
1 any structure priorto statement
that
he isa-ored pursuant to
uch ions of cit e
3 Elea sued statement that he-licensed pursuant it the Prov-Ions of the ]OWER DEVICES
ContrO w I..3 fIhc License law(Chapter 9(mmmorthat with Section 7000)of Divi- SWIMMING POOL ELECTRIC
u, �S slon3ofthe Business and Professions Code)orehat he-exempt thereiromand VALUATION �-
y the bas-far the alleged exemption. Any violation of Section 70115 by say OUTLETSSWHGHESEXTURES 7APN
ppllcantfora pennit subjectstheappllcanito a civilpeiulty of not more than five hundred dollars%500). NEWRFSIDEMiALELECIR❑I,as owner of the property,or my employees with wages as their sole SQ'FT" STORIEScompensation,will do the work and the structure-not Intended or offered forsale(Sec.7044,Business and Professions Code:The Contractors Wrense Taw
does not apply to an owner of property who builds or Improves thereon,andwhodoessuchworkhimselforthroughhisownemployees,provided that such OCC.GROUPimprovements are not Intended oroffered forsale.11,howevegthebuildingor TOTAL: a,LTU
Improvement-soldwithinoneyearofcomplOton,theowner-buBderwlllhavelQlurdenof pmving that he did not build or improve for purpose ofeale.). ,Q'py; ''FEUMBINCPERMFF FEE FLOOD ZAN
R I,as owner of the property,am exclusively contracting with licensed
contractors to construct the pmject(Sec.7044,Business sad Professions Code: PERMIT ISSUANCE
The Contractor's License Law,does not apply to an owner of property who
buALM-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon,and who contracts for such ptojem with a
cq�actorW Burned pursuant to the Contractor's License Law, FEE SUMMARY'
LJ l am exempt under Sec. B &P C for this mann BACK FLOW PROTECT.DEVICE.
OUTSIDE
rlv
.or Date S R, -A'ro�'
DRAINFLOG ROOF, SANITARY Y_" N—
RECEIPT«
WORKMAN COMPENSATION DECLARATION TnURES PER TRAP .,-a S I(JULT'AX Y N
�I hereby affirm that I have o certificate of consent to copy
ythereof or RECEIPT M
alflcate of Workere'Compennatlonlnsurance oracertified copythereof(Sec. GA EA.�'S IM-I O ET 5!l
3800,Lab yry �} t ] PARK FEE y N
' 1'ollq«� 6�OD/ �1] J - ' RECEIT'f#
Co anv CAS ;SYSTEM-OVER4(EA);
BUILDING DIVISION FEES
ff.myCertified copy-hereby famished. 'GR %INDUSTRCW I r E'^ PL -IECK FEE
CertlRed copy-filed with the city Inspection division. 1 `
+ CERTIFICATE OF EXEMPTION FROM WORKERS' RFdeF -� AIDf__` "���� `• �B
COMPENSATION INSURANCE -SAN(7ARy-STORM FA 200FT. , Date Recei f#
(Thisaectlo,need not I e completed If the permit-for one hundred dollars
($100)°`lean') WATER HEATER W/VENT/ELECTR NERGY FEE Y N
Ifmices.) inthe performanceof thework(orwhlch thio permit is-sued, —
1 shall am employ any person In any nanner so an to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PA
0 Z Applicant
Z p NOTICE TO APPLICANT'..If,after nuking this Congleate of Exemption,you NEW RESIDENTIAL PLMB. �.Ff. to Recei t#
should become sub)ect to the Workers'Compensation provisions of the Labor OTAL:
W Code,you most forthwith comply with such provisions orth-permit shall be BU Di t,
j deemed revoked. ev
W CONSTRUCTION LENDING AGENCY - SEI MI p
d Ihereby affirm that there is a construction lending agency for the perform, EL CTRIC FEE
7 Z scare ofthe work for ich V.mut le Issued(Sec.3097,Civ.C3 TOTAL: CP
00— Iendem Name ��� PL WING FEE
14, L) Lenders Addren p?'Y. . 11�E_CHANICAL PERMIT'.. FEE _ M CHAMCAL FEE
0 W ertifythatlhave res th pppllratlonandstatethattheabovelnformation
CL Is wmd:I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FE SPAID:
} reladngtobuilding construction,and herebyauthmom representativesofthl,
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. -
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
O against liabilities,judgments,onessand expenses which may in anywayamme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City nsryuence of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CPM) CO TRUCTIONTAX
Signature° ppicant/Contractor Data EXHAUST HOOD(W/DUCT CONS UCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 103,000 BN) Date Recei t#
material an defined by the Cupertino Municipal Code,Chapter 9.12,and the
I iealth and Safety Code�+.-S�ection 25532(a)? HEATING UNIT(OVER 100,000 BTU) T TAL: t70.
F1 Yes u No
Will the applicant orfuture building occupant use equipment or devices VENnLATION FAN(SINGLE REBID) ISSUANCE DATE
which emit harardoua air contaminants as defined by the Bay Area Air
Quality Management District? MOILER-COMP OHPOR 100,000 BTU)
Yea
❑❑
have readleaawrdoua Fmateria- h E2
requirements under Chapter 6.95 of BOILER-COMP(OV100,000 BTO) �^
ealth&Safety Code,Sections 25505,25533 an
dC�Rfornialld 255 I J
understand that if the building dues not currently have a tenant,t tarry NEW RESIDENTIAL MECH. 5Q.FT.
responsibility to notify the occu nt°f thereqnry.uirerrcntswhich ustbe
priorto-suanceofa olOavpa-eOW - -
ser or _ Da - �/�}}' ������sI4,����a�sj���.s
TOTAL: ISSUED 6`f�JCJC�'r�a/�"J
OFFICE COPY