21810 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification 1 G (,:;KA--w-)<- PERMITNO.
Building Address:
A01471-V3. WVJ4 APO *_203Lr 21810
neve arse: one: A
Fox -�'v 14W. I.XL'S CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lic.Na APPLICATION /PERMIT Z-5�
1ect/� BUILDINGELECTWCAL,PLUMBINGMECHAMCAL CATEGORY CONTR0611.
gtneer.y 1 y'� LJ�No: �Jb
a��/UaS IO /✓JJ�SI G'NS CaJSP Z QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: /G 0a:' A-Z/Z PERMITISSUANCE ('� ® LL O ❑
5 C O
Hemb eRirmthat lam Bceneed under rovlalonn of Ga 9(commmc- APFTIANCFSRESIDENTTAL
Y P prey IOB 9FSCRB'TION
ingwithSection 1.fullforceofdeffeon3o(theBualncsaandProleslonaCode,andmy
Lialicenrs is In s force and c.it PANELS 11 y
D.tCbrs Lk.X
Dace Gantrador UP TO 20AMIS
ARCHITECPSDECLARATION 00 AMPS
re02 (understand my phnsaluBWuned arecords,public correcords, OVEROVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FI'.
POE Licensed Professional SIGNS ELECTRICAL
G<R. OWNER-BUILDER DECLARATION
in SPECIAL CIRCUIT/MLSC
Lp ,-Jx Ihercby affirm that lam exempHromthe Contractor's License Law for the
.,�
OZZI :/ following reason.(Sectlon 70315,Businessand Professions Code:Anycity or TMRMETERORPOLEINST.
countywhich requirrsa permit toconslrud,alter,Improve,demol ah,orrepalr
F'`5 r5�:3 anystmt mprlortoltstsvrance,aL,,g. theappBrantforsuchper tto POWER DEVICES
C file a sued statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(mmmencingwith Section 70W)ofDivi-
F�OQ sion3ofthe0usiness and Profesnlons Code)orthat he b emmpt thercfromand SWBriMING IDOL ELECTRIC VALUATION
g ¢5J the b s s for the alleged exemption. Any violation of Section 70 31.5 by any / OUTLE SSSWITCHESFIXTVRES
applicant fora permit subjects the applicant to a civil penalty of net more than
a. O� five hundred dollan(SM.
NEW RESIDENTIAL ELEC7R SQFC. STORIES 'TYPE CONSTRUCTION❑I,as owner of the property,or my employers with wage as their sok
JQ componsatio4,Business and rendthestrude:TheCIntended License
D sale(Sec.7014,Business and Proferslons Code:The Contractors License Law
does not apply to an owner of property who builds or Improves thereon,and 0 Ga00 C.CROUP RES.UNITS
who does such work Iimulforthrwgh hisown employees,provided thats ch I
Improvement arc not Intended oroffered forsals.If,howeveq thebullding car TOTAL:
Improvements oId Mthinaneyearofcompletlogtheowner-WBderwBlhave
Fthn en of Proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
tractors to construct the pm*d(Sec.7014,Business and Professions Code:
Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
e
Wilds or Improvthereon, and who contractsfor such py)eRs with a
cgLLt set 0)licensed pursuant to the Contrader's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this rcasnn
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEBT X
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that I have a certiBate of consent to sel4w
lnre,ora RFGER'1'X
cenifimteof Workers'Compewtlonlre ranmoramAifled copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT X
Policy N GAS EA.SYSTEM{OVER d(EA) BUILDING DIVISION FEES
Cam ny
(Red copy t hereby famished. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE
Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ER S' CREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANI.I.ARy-yTORM EA 2(IOFI. Date R t# E3J
Rhlsseetlon need not W complded tithe permit h forone handrail dollars
(Slop)ne less.) ENERGY FE
Immlythat lnthe performance of the work for which thus Permit is asued, WATER HEATER W/VENT/FLECTR y' —
I shall not employ any person In any manner so as to become Qt
ecoe subject to the S
WATSYSTEM/TRG]ING
Worker Compensation(awe of California.Date PAID
OTICE TO APPLICANT:If,after making this Certificate of Exemptioq you NEW RESIDENTIAL PLMB. SQFIliran ': Ieee1 [#
ZZ N
0should becomcaubject to the Workers'Compensation provisions of the Labor T AL:CC
�/�
N Code,you must forthwith comply with such provisions orthis permit shall be BUILDINGE Xw
W j decucd revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE t V
a 1hembyaffirmthatthem Is a construction lendingageney forthe perfi TOTAL ELECTRICFEE 4,�
Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.)
U O LendarsName PLUMBING FEE
LL I- LenderSAddress QTY. MECHANICAL PERMIT r'.. MECHANICAL FEB
O W I cently that l have read thisapplicationand satethattheaWve information
1 um
corr .Iagreeto comply with all etyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorities t
e representatives ofth
F. Z citytoenterupont above-mentI red for inspection purposes. ALTER ORADDTO MECH.
(We)egr t e,Inde p hMess the City of Cupertino Date Reeei t#
V agairetlia ti ,.,'g e Z. penes hlch may In anyway ayrue AIR HANDLING LMT(TO 10,000 CEM) SUBTOT L:
tym n of the anti of this perry;. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER I otiocFM)
M. arae plant/Contractor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA
HAZARDOUS MATERIALS DISCLOSURE
illtheappllcant or future building occupantstore or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Receip #
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Iiealthand Safdy Code Section25532(i)i HEATING UNIT(OVER 100,0 BTU) IOTA '
❑ Yesri No
Will the a ppllcaut or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RMD) `'$$ {s1,CE DATE
which emit hazardous air contaminants as dented by the Bay Area Air
Quality Management District'! BOILER-COMP OTB'OR 100,000 BTU)
Yes n No APR
e5 11Q
4havcrcadthe
ia I ealth&rafetyCde,Setions2505,25533and25534.95of OO LER-COMP(OVERIW,000BN) ']11PR f 1 1x7
91
the
erstan that
lith&Safety Code,Sections 25505,25533 a tenant,that
undorstndytontif the ougdces net corequire have which that homy NEW RESIDENTIAL MECH. SQ.�
pnortorouytoofa Ctheoavpantoftherequirementwhich mustW coed �(slpa�Sf�1nn^ 'r
prior to Lvuance da CertlOate olOmpancy. N��aY��� �Q�,}._ 1
Owncror eWhoriced agent Date ISSUEDBYQW1`/0 /�'-��"�V'�Y
TOTAL
OFFICE COPY