20304APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
9alldb` Pra ed Idemi(Icatian
Building Address:
!Oioo E 0 I o Di i
PFJNIT NO.
7 O O n
20304
G 4
YC t% cane
ES
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION/PERMIT
BUILDING-ELF-CTRICAI-PLUMBINGMFOHAMCAL
APPLICA nON SUB=ALA IL
'5 O
Contractor.Namo; Lk. N.
CATEGORY
CONTROL X
Architect/Engineer. LW. Na
QTY "ELECTRIC PERMIT "FEE
BUILDING PERMIT INFO "
Address:
le I-iy I�Y
1=1 u
PERMITISUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebyaHrem that l am llcmwd under provisions of Chapter9(commenc.
7000) of Dlvfect. (the BualneasmdProfesslonsCode, and my
Ingwlth I.
licanss Is In full (arm and affect.
Licenw Clam LIC#
APPLIANCES -RESIDENTIAL
O�DFSC N
���
PANELS
Date Cantndor
ARCHITECPS DECLARATION
I understand my pians shallbe used as public record..
Limned Professional
OWNER -BUILDER DECLARATION
I hereby afBrmthat I am exempt from the Contractor's Limo Law for the
cmnt whichog equt cHon7R)I.5, Business tommmoaMPimpmw, e"lishnydlyor
countywhlc pre toiup a e,a6o quimotheaprovgdemolth,ormpairadtto
any atmeNrepalortoithat1.Inlice sed pu ...tt the foraubmaof t e
file a signed statement That M t licensed pursuant to the provisions of the
Contractor's License Law (Chapter 9(conurencing with Section 7000)of Divl-
al0n3 ofthe Bush euand ProfembanCode)orthat he In exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appllcant(ora perrnit subjects the applicant boa civil penalty of am morethan
five hundred as
ewner Itheprrs .
❑ I, as owner o! the ewperty, or my employee with ended as there sok
compensation, winIda,1mad P,and f.i. atmmrehe Is Cma cto?nded oicenseLaw
vie (Sc. applyot tit, to an o a end f grope ty Cady. TM Contractors Wmo Law
dens ocasucloan owner ofp rough who Wildaoyees,pvethereon, thatand
such/"'
who provemnts workam not
thimself odmattered
atgh Meown e. If, howeverthe buil angor
Improvement ared within
Improvemenitwld within aneyearo(compldloMtMowner-Wilderwill have
theft ever,theerwilI haw
tflittIurden of proving that he did not build or Improve for purpose ofsaleJ.
u L as owner of the property, am exclusively contracting with limned
to construct the project (Sec. 7014, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wlids or improve thereon, and who contracts fen such pip" with a
cga3rectw(e)Rmneed P..mtrothe Contractors Lias..Law.
I am exempt under Sec B k P C for thin reason
201-1000 AMPS
OVER 1000 AMPS
SQ. FT. FLOOR AREA
/ /J9
L[l9U
'
S/SQ. FT.
!!!
SIGNS IT
SPFOIALCIRCUIT/M15C
�(p MEfERORPOLEINST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESFIXTURES-
VALUATION
NEWRESIDENTIALELFOTR SQJ7
STORIES
TYPECONSTRUCTION
�N
-a'
,] rS Q(
TOTAL:
QRy,PLUMBING PERMITUlfI B IIf)
U OCC.GROUP
FLOOD TONE
"
RES UMTS
APN
PERMIT ISSUANCEcontracture
ALTER -DRAIN kVENT - WATER (EA)
FEE SUMMARY
- BACK FLOW PROTECT. DEVICELI
'DRAINS- FLOOR ROOF, AREA, COND,
SANITARY Y N
RECEIPT #
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm certificate self-Inure,FIXTURES.
that 1 have a rtificate of consent to or
38W,L.bC.) rkers Compewtlmlruunnaweartifled copythereo((Bec.
3800, N C.) '
I'oliry N
PER TRAP
SCHOOL TAX Y_ N_
RECEIPT #
GAS P.A. SYSTEM4 INCAOUTLM
PARK FEE Y N
RECEIPT M
GAS. EA.SYSTEM-0VER 4IRA)
Com a -
BUILDING DIVISION FEES
rifled copy is hereby tthedd.
Ceriffled copy is filed with the city inspection division.
CERTIF'ICATEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit tfor one hundred dollars
($10C)orlaaa.)
I mortify that N the performance of thework farwhlch this permit is issued,
I shaB not employ any person in any manner w a to become subject to the
Workers' Compensation laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after nukinglfi
this Certificate.f Exemption, you
should beroms subject to the Workers'CopmuaUm pmnig rs ofthe Labor
m
Code, you must forthwith comply with such provision ortht permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby a(Onnthat there t a constmdlon lending agency forthe perform-
ane of the work for which this permit t issued (sec. 3097, CM C.)
Lander. Name
Lmder'.Addnree
I¢rtifythatl have readthtapplicatlonand maMthatthe above Information
tcomr,t. I agreeto comply with aB city and county ordinances and state laws
relating to W (Wing construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property fen inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities,ju dgment, costs and expense which may In any way acme
agaWn
Sigrsure of Applicant/Conractor jr 115 Win
HAZARDOUS MATMAOMSDISCLOSURE
Will the applicant orfawre bufiding occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter9.12, and the
HeallhmdSafetyCodn SMIon25532(a)I
❑ Ye N No
Will the applicant or future building occupant uv equipment or devices
which emit hazy ldom air contaminant fir as deed by the Bay Area Air
ality Mawgement DlaMct7
Yd Na
' � ve read the Fazardous malerlale requirement underChapter G95 of
P.:alRomt Healihk Safety Code, Sections 25505,25533 and 25534. 1
".nderatand that lithe Wilding does not arrently have a tenant, that It is my
responsibility to notify the occupant of the requirements which must be rrat
prior to Issuance M a Certificate of Om pancy.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date Recei t#
GRFASETRAP
SEWER -SANITARY -STORM EA. 200Ff.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Remi t#
WATER SYS177d/TREATING
NEW RESIDENTIAL PLMB. SQ.F7.
TOTAL:
BUI
SEISMIC FEE
TOTAL:
ELECTRIC FEE
PLUMBING FEE 3
.-"
QTY. "_ i `MECHANICAL PERMIT" . • -FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Dale ReCel t#
ALTFRORADDTOMECH.
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL: a%
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DLC'D -
CONSTRUCTION TAX PAID:
"
Date Recei t#
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 10(1,000 BTII)
pp
TOTAL: CO.%
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
/L ey�
�`a97p
n'l
sit( of rlinp/fjnfl
ISSUED BY:
BOILER -COMP (3FI'DR 100,000 BTU) -
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT.
Owner or authorized agent Data
TOTAL:
OFFICE COPY