21492 APPLICANT TO FILL IN-INFORMATION WITHIN REDLINES —.USE BALL POINT PEN ONLY
Building Pre en Idendfication + PERMIT NO.
Building Address: n A'n .
. —, G 4T J
wnera : ne: - 11 1p
7 T 'O:5 Z'CITY OF CUPERTINO-BUILDING DIVISION � Q
N
o-ado. Name: Lk.No:1117 t p APPLICATION L PERMIT
4L7G� V U IJ -ILRLDING-ELECTRICAI.PLUMBINC-MECHAMCAL CATFi..ORY CONTROL If
Itect/Engi ear Lie.No: ..
" h ' "' " 11`- '" `' a, r+' BUILDING PERMITANFO.
'QTY ELECTRIC PERMIT " i " FCL " ' �,•
Address: 2 /•� w-, �-r1 p-�
. e PERMITISSUANCE IX -� JCI
LICENSED CONTRACTOR'S DECLARATION ✓� LJ
I hereby afflrmthat l am Bcemed under pmvbions Of Chaptar9(.monenc. APPEANCES-RE ENTIAL .DD JOB DESCRIPTION
ingwith Sedion7000)of Dlvlston3 ofthe BuslnessandProfesslonsCode,and my
license le In full rae d effM. PANELS
License Clam- Lic.p"� / ` 1 /�.v--YI, V �l
Dale °nt_ e,( 111 `.,
ARCHITECTS D CLARA ION 2iii.ictioMi4ps
pQ
��2 Iundentand my plana shall be used upublic rerords ' OVERI AMPS 5Q.IT.FLOOR AREA $/SQ.FT.COC
E `j Licensed Professional. .•. SIGNS AL ' ,
«<< OWNER-BUILDER DECLARATION l gpp� (ET �D
I hereby affirm that l am exempt from the Contractor's License law for the
Fg � following reason.&Cie.7031.5,Bualdmnenand professions Code:Any dtyor GMP. LTR OR POL IN
F" county which requires a permit toconstru ,alter,improve,deolbh,orrepair
Q nystmeture prior to its bsuance,a so requireatheappllmt forsuch permit to
V file a signed statement that he is licensed pursuant to the provbiom of the
ntPOWER D CES -
Oe:�p Coractors Licensm
elaw(Chapter9(comencing with Sedion7000)Of Divi- POOL OL C
elon3ofthe Business and)'ro(essbroCode)orthat he bexempltherefromand VALUATION Q p
< the basis for the alleged exemption. Any violation of Section 7MI.5 by any OULETSWICHS
applicant fora permit aubjecttheapplleanttoa civil penakyof not mumthan - ,
dD
w p five hundred dollars(5500).
NEW RESIDENTIAL FLUMESQ.IT. STORTA TYPECONs➢RUCTION
F-1 1,as owner of the property;or my employee.with wages as their sole
7a compensation,will do the work,and thestrudure b net Intended or offered for
❑ sale(Sec.7044,Business and Professions Code:The Contractors License Law
x'$ does not apply to an owner of property who builds or improves thereon,and
'S^ whodees.uchworkhlmselforth=ghhisownemployees,providedthatsuch ••�� OCC.GROUP RFS.UNITS
Improvements are not intended muttered forsale.If,however,thebullding or TOTAL:
Improvement baold within omyearofcomplelion,theowner-buBderwgI have
t�r rmc.of pmvingthat he did net build or improve forpurposeofsale.). QTY. ; "''' 'PLUMBINGPERMIT,' -• FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE m
entre"".to corohud the project(Ser.7044,Business and professions Code: �Qv
The Contactor'.License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wllds or Improves thereon,and who contracts for such projects with a -
_ '•i'�' FEESUMMARY '
cQ_jIartaexemp'under ee to the Contractors License Law. BACK FLOW PROTECT.DEVICE
u 1 am exempt under Sec. B&P C far this reason ' OUTSIDE FI ES
Owner Date DRAINS.F[OORROOp,AREA,COND. SANITARY Y N�-
RECEBT#-
•• WORKMAN COMPENSATION DECLARATION
❑I hereby affirm ce
that I have a rti8cepD(TURES PER TRAP SCI100L TAX
te of consent to aelf-Insure,w a �' D Y_ N_RFOE Pf#
mnifimteofWorken'Comper tlonlruumnmoramrtgie mpythereof(Sec.ab C.) _ GAS EA.SYSfFAf-11NCA OUTLETS Otj. PARK FEE Y--N
PnI1ry olicy N /� RECEIPT It
GAS EA.SYSTEM-OVER 4(FA)
Com any - BUILDING DIVISION FEES
• FCertlfied co reby tuml.hed. •, GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE sEwER-SANITARY-STORM F.A.200FT. Date Recei t#
(fhb section need no[W completed tithe permit b(Drone hundred dollars
(5100)gr less.) WATER I]EATER W/VENT/ELECTIR ENERGY FEE .Y N
I certify that In the performance of the work for which this permit is issued, '
I shall notemploy any person in any norms,so as to b eubjed ttq the
WDrkems Cg9s��ltppensidiVQ�jw.of Ilforia.Date 1�' —C�V WATER SYSTEM/TREATING PAID
O Applicant 'K ILC �As._P
Z 2 NEW RFSTDENTIAL PLMB. SQb7. Dale Recef t#
O NOTICETO S.�'I CANT: ,after nu Inger this Ertl rate of Exemption,you
should become subject to the Workers''Compensation proeist Ofthe Labor TOTAL:
�
N Code,you must forthwith comply with such powbious or this permit shall be G •G L 7 0
j• deemed revoked. BU r
T I G CONSTRUCTION LENDING AGENCY SEISMIC FEE r O
Z IherebyafBrmthat there bacoustrudlon leMingagenry Torahs pedormn TOTAL: 16-100 ELECTRIC FEE. p•
M ance of the work for which this permit 1.Issued(Sri.3097,CW.C.) -
V'O Lender'.Name
. - - PLUMBING FEE b-00
f- . Lenderapddre.. Qrt. ' MECHANICAL PERMIT
LL U Icertlfythatl haveread this application and suatethat the abovelnfonwtlon / MECHANICAL FEE
O W Iscorred.I a gree tommply withal)city and county ordinances andstate laws ( PERMIT ISSUANCE' ;L.00 FEES PAID:
4 relating to Wilding construction,and hereby authomax,representatives of this -
F N city to enter upon the above-mentioned property for Wpectionpurpose.. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify an d keep harmless the Cltyof upertino Date Recei -t#
V against llabill ,judgments,.9...d e.pen.es which may In any ways.. AIR HA NDENG UNIT CFO 10'"CFM) SUBTOTAL:
a uid 1 Io con ence of the Bra nting of this perm-
: _ aR)iANouNc uillT(OVER tB,eBaCFM) CONSTRUCTION TAX
' SI n rcof ppi / nbnd°r a IXFiAUS'f HOOD(W/DIX:'D a
CONSTRUCTION TAX PAID:
lARDOUS MATERIALS DISCIASURE -----
Willthea cantor future building occupant store or handle hazardous. . HEA TING UMT(T0100,000.11M
rr g r Date Recci t#
material as def) -by the Cupertino Municipal Code Chapter 9.12,and the - --
1lcalthandSafetyCcai Se 25532(a)7 ' HEATING UNIT(OVER 100,000 ITLEI TOTAL: '
❑Yes o°n
Will the applicant Or future building Occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUA1I%LQEDATE
which emit hazardous airconbmmants as defined bythe Bay Arca Air PAP -
Quality Management District? BOILER-COMP OR 100,0(10 BTI))
4 Yrs �!0 n1 q
S havcread lealthhe a et Code,Sections
25505,25M3 and
255 .I of BOILER-COMP(OVQR 100,000 BTU) ''YQ�,F d ja.90
theerstann flat it the
Code, otcurrently have a tenant,
- ' " I'1
understand it the tify the Occupanting does oft errentlyhrrot,w which
that it busy NEW RESIDENTIAL MECH. SQ.IT. ^
rr.p°nsibllity o.artifil teantcupancyuircmentswhlchmustbemet City ofPliDrgrllM
p' rt Lssua tufa Cemfi tr of Occupancy. p � � Y -
ne orauthoriad ge ( -Dae r�i,a,-•a ISSUEDBY:J-
TOTAL: 1/
- :OFFICE COPY .