22460 (2) APPLICANT TO'FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
ging Add Building Project laemumamn- y l , ' - PERMIT NO.
2,2 4 6 0
7. a`410EV�IJS Gt2EC3K 1?e{nrd� ,�rlf/ ( `'(J
wnero 'x one: ALOAII,
�naNti AM ; 1� CITY OF CUPERTINO-BUILDING DIVISION' ��I
Contractor's Name: Lic.N.: APPLICATION /PERMIT
BUfLDINC—aF RICALI'LUMBINC MECHANICAL CATEGORY CO
Arc /Engineer. . \ Lie.No
N G BUILDING PERMIT iNFO . , t
QTY :ELECTRIC PERMIT, �� .PCC -
Address: Ns' ka PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that l am llcened under provisions of Chapter9(comment, APPLIANCFSRESIDENTIAL- JOB DFSCRRTION
Ingwith Section 7000)ot Divlslon3ofthe Buslneaand Pmfesdon.Code;and my
license is in full force and died' - PANELS
Lio:rseCla® III- 133%,5
Date_/r- 5 Contredo, ,s P' e_,.n7S'1, LIE IQ20QAM
ARCHITECTS DECLARATION PS
OVER 1(1(10 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Ob I understand my plans.haB be used as public records. r� Lk t,
Licensed Professional - EGNSELECTRICAL L�"lit _ �
< OWNER-BUILDER DECLARATION1 —,
t0
` '
Thereby armlhatlamexempt(mSPECIALCIR&T/MISC
from Contractor's License law for '
p following reason.(Section 70315,Business and Professions Code:Any city or
r4"❑� countywhkhrrea
qulaper ttommtmutalter,Impmve lh
,de=llormpalr TEMP.METERORPOLE(NST.
anystmcture pri.rto Its lsaaance,also mqulreathe applicant for.uch permit to POWER DEVICES ,
rxGV file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License S (ChapterLaw 9(commencin with Section 7000)of Divi. VALUATION OS
Mon Buslressend Profesel.nsCods)orthaghe is emmptthemfromand SWIMMING POOL ELECTRIC
Sn the basis for the alleged exemption. Any violation of Section 70315 by an
OUILETSSWITCHESFlXTURES '..
O applicant fora permit aubjedsthe eppgcanttoacivll penalty of not mare than $
five hundred doll ($500). SQ,pr, ( • C NSTRUCTION
ars NEW RESIDENTIAL ELECTRU \I
ow
MI,as ner of the property,or my employees with wages as their sole
compensation,wllldothe work andthe structure b not intended or offered for ER .
Ovie(Sc.7064,Business and Profevlons Code:The Contractors LlcemP e Law � Y U
eg does not apply to an owner of property who builds or Improves thereon,'and
i OCC.GRO / �ES I1NffS
who .,through his own employees,provided that such .g
Improvementsare not Intended stuttered forsale,If,hownvepthebulldlegor TOT TE �.i
Improvementissoldwithinoneyearofcomplelon,themvner-builderwillhave ,
t)�ekurden of provingthat he did not build or improve for purpose ofsale.). GTY. PLUD'MBINGPERMIT"',�1 Q'fE1;",,. FLOODZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMITISSUANCIR
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contndor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER LW
or Improveso
thereon, and who contract. for such Inpocts with a ,'FEE SUMMARY
cgtlt our(eI licensed pursuant to the Contractor's License Law, gpCR FLOW PROTECT.DEVICE l
LJ I am exempt under Sec. B k P C'for this mason ,ry -
' ex
Owner Data {/ DRAINS FLOOR 0 ROOF,AREA,COND. . SANITARY Y_ N_
RECFR'r N
WORKMAN COMPENSATION DECLARATION FIXTURES,PER TRAP SCHOOL TAX Y_ N
MI hereby orkam filren that I have o I mourancificaus.f consent to op theure,ora RECEIPT N
3800fi abC()W.rken'CompemaHonimurance gra certified copythemof(Sec. L GAS EA.SYSTEM4 INC.4 OUTLETS ro�. PARRFEE Y_ N
RECEBT N
Policy. p GAS FA.SYSTEM-0VER4(EAI
Com any - .' BUILDING DIVISION FEESNCertified copy is hereby furnished. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE'
Curtailed copy is filed with the city inspection division. /s��
CERTIFICATE OF IX[MPI'ION FROM WORKERS' GREASE TRM r PAID—' `8-q` �pl•t,� (y
COMPS SAT10N INSURANCE - ' SEWER-SANTCARY-STORM EA.]OOFI'. Date RCC21 1# -Is
(Thi..ac ion need cad be completed Rthe permit is furore hundred dollars
($1(JO)or less.) WATER HEATER W/VENT/ELECTR ENERGY ITE Y N
I certify that In the performanm of thework!.,which this p.141,beard,
1 shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Worksm'Compensatlonlaws of California.Date PAID
O Z ' Applicant f#NEW RESIDENTIAL PLMB._SQJM Date ReM
Z O NOTICE TO APPLICANT:If,after total ng this Certificate of Exemption,you
Hshould become subject to the Workers'Compewt Ian provisions of the Labor . TOTAL:
CCN Code,you most forthwith comply with such provisions orthb permit shall be BU WING W ] deemed revoked.
a cCONSTRUCTION LENDING AGENCY SEISMIC FEE
I here by affirm that there is a construction lending agency for the pattern, IOTA : rZZO�L ELECTRIC FEE eZ
7 Z anmoflhew.rkf.rwhlchthL permt'l 6sued(Bec:3097,Civ.C.)
U O Ianier.Namn - - - PLUMBING FEE'
H I.ender.Addre.. QTY. MECHANICAL PERMIT FEE
LL - MECHANICAL FEE
O W Cued..haH havemad mply with allcitynand dcoutoyordfinancesoothat edgatelaws
S bcorelatingt bagree ng comply tioo building n,andtyand muntyd hamby ice repnceaand ps ofthis `. PERMIT LSSTIANCE '� FEES PAID:
r Z
city toenter
l.gma to ave,he indemnify and
property fee Inspection the Cit purpose.. AL7E2OR ADD TO MFCH. Date Recel t#
lsa agree to save,indemnify and keep harmien the City of Cu accruo P
agalnnt llabllltles,judgment,coos and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaimleai City in consequence of the Ip otirgotthispeomlt AIR HANDLING UNIT(OVER Ig000CFM) CONSTRUCTION TAX
za;�
1/_6CONSTRUCTION TAX PAID:
flInonfirc of Aant/Contradnr Data D(HAUST HOOD(W/DIX:T) "
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building necopant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reuel t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
I leach and Safety Code Sectiom25537(4? "" HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yeallo
Wllltheapplicant oo tumrebulldingoccupwauee equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE:
which emit hezardom air conlamlmntsa,defined by the Bay Area Alr
Quality Management District? BOILER-COMP LIHPOR 100,000 BTU) - P M A ' D
4Yea o
h averead the haze outnulerla requiremensunderChapter6.95of BO ER-COMI (OVERlIX,000 BTU)
the California Health&Safety Code,Sections 25505,25S33 and 75534. I NOVunderstand that lithe building doeses MI
ncurrently have.onset,that It is my NEWRESIDEALMECH. SQ.L' N
T. 1091
prioHo LattuamrdRylheocte of ofthe requlrumem.which rtwsl be mel v
resorts nee notf a ify
Certificate avpa reqs a
�—
CITY
UFF•�U,UUPE�HRNU.
Owecr.r oto rind agent Dt) a ISSUED B1VjL/Q7
OFFICE COPY