21868 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'cn IdentificationPER.WT NO,
B°Bding Address: / 21868
0/Z3 N. E
LJOIf� � SPs �3a
TTW_mere ante: C'� one: A
Z-1177/T�� �W� CITY OF CUPERTINO-BUILDING DIVISION
Coro-nota Name: LIoNce APPLICATION I PERMIT J q
. A Iters/En r r/ Lle No: BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CO V
1-Y-J11� J BUILDING PERMIT INFPO
�� 9/& 73/—N sO QTY ELECTRIC PERMIT FEE
Address: (� SKY PERh1IT ISSUANCE ❑ F-1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby e(llrm that lam licensed under prwi.ions of Chapler9(convnenc APPIIANCESRESIDENTIAL JOB DFSCROTION
ingwilh Section 7000)of Division 3 ofthe Business and Professions Code,and my
license is in full force and effect. PANELS 11
Lirense Chs Lich TLX r
Date Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
Z I underete cid my Flat as shall be used as public record a. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
D 11'•IIS-Js O.
HU
SIGNS ELECTRICAVJUA
23 O
�4 U iu Licensed Professional
<Qw OWNER-BUILDER DECLARATION
�n}fdSPECIALCO2CUIT LSC
n
r- 7� Thereby affirm that lam exempt from the Conlnor's License Law for the
09t- following mrson.(SMIon 70315,Business and Professions Code:Any city or TEMP.MEIEROR PO LE INST.
countywhich requlm a permit to constmM alter,improve,demolhh,or repair
�� anyatmm,re prior to Its Lsasance,ai.orequlm theapplicant forsuch pemdt to POWER DEVICES
KK I file a signed statement that he b licensed pursuant to the provisions of the 14
�3 G Contranor'.License Law(Chaptcr9(..edngwith Section 700))ofDwi- SWEhmNGPOOL ELE TRIC VALUATION
�Og sion 3 ofthe Business and Profenions Code)orthat he is exempt themfmm and
!!��y.'•�.1 the basis for the alleged exemption. Any violation of Section 7031.5 by anyOI17LE.ISSN7.fCHES}lXi'URES `
/1.�a L o2O`CM
lyo appb..t fora permit subjects the applicant Ica civil penalty of not morethan '�1 7f
G LLSS Q five hundred dollars(SW. NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCTION
F1 I,as owner of the property,or my employees with wages as their sole
C7Q compensation,wlllelothework,:ndthestmcture hnomitended or offered for
g O sale(Sec.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
who does such work himaelforthro sigh hisown employees,provided that such
Improvements are not intended oroffered forsals.If,however,thebuilding or TOTAL:
i pmvementbwld Mthinoneyearofcompletion,theowner-buBderwEl)uve
N
t en of proving that he did ran build or bmprove for purpose oleale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
UI,as..or of the pmpeny,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professbra Code:
The Contractors License Law does not apply to an owner of property who ALTER A
Wilda or improver thereon,and who contracts for such pwjects with a FEE SUMMARY
<�B(anor(s)Iicenend pursuant to NContractor's e Coactor's License Law. BACKPR rG D
EF1LJ I am exempt under Sec. B k P C for that reason OUTSIDEFEES
Owner Date DRAIN SANITARY Y_ N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION /�
�.
01 hereby affirm that I have a certificate of consent m self-insure or a FIXTURES /O � 7 SCI100L TAX RECEIVE N
certificate o(Workere'Contpematloolmurance or a certif4d copytheeof(Sec. GAS EA.SYSTEM-1 INCA LTS P NR FEE Y N
3800,Lab C.) — RFGGBTN
Polity N GAS EA.SYSHM-OVER 4(EA) BUILDING DIVISION FEES
Cam
MCertifiedy
copy is hercbyth thhty GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHPCKP
MCenBled copy h filed with the city inspection division. ���.L�
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIEASE TRAP PAID -
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date RLY 1 I#8-7r,s
(Thi.sectmn need not be completed lithe permit Is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ENERGY PF,E �Y�_ N
I ceNfy that In the performance of the work for which this permit Is Issued, �lpQ�
1 shall not employ any person In any manner m n to become subject to the CID
Workees Compensation Lawsof CallfomWATER SYSTEM/TREATING, PAID
la.Date
Applicant
TO APPLICANT.U,after making this Certificate of Exemption,you NEVJ RESIDENTIAL PLMB. SQFT. Dale Revel
Z Z N
O should become subject totheWorkers'Compensation provisions ofthe Labor TOTAL: �t
CC
L
Code,you must forthwith comply with such provhiara orthh permit shall be BUILDING FEE �T
j deemed revoked.CONSTRUCTION LENDING AGENCY EISMIC FEE
[l F3 1hembyaffirmthat there ha construction lendlegagency,forthe perform LECTRIC FEE
Z ance oflheworkforwhlch that permit is lnued(Sec.3097,Civ.C.) TOT
02 Lender.Name LUMBING FEE
LL. 1— LendersAddren QTY. MECHANICAL PERMITECHANICAL FEE
OW 1unlfythatl have mad thhapplicatlonand statethattheaboveInformationsmrren.Ixgreeto comply with all city and countyonlinancesacid nate laws PERMIT ISSUANCE E-S(°AID: �Z �/relating to building construction,and hereby authorze representatives ofthh s+(--/tel/// lfAcity t°enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.? e)agree to ve,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V a hbilitlee menta s and expense.which may in any way ac=e AIR HANDLING UNIT(TO 10,000 SUBTOTAL:
al aid I s fthegran tingof this permit. AIR HANDLING UNIT(OVER 10, C . ONSTRUCTION TAX
A scant/Contractor ate EXHAUST HOOD(W/DIK'D CONSTRUCTION TAX PAID:
LftfC HAZARDOUS MATERIALS DISCLOSURE
ill theappllcam or future building occup.m.mr,or handle hat.rdou. HEATING UMT(TO 100,000 BTU) Date Reuel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
lie Ith and Safety Cod cioo 2S532(a)? HEATING UNIT(OV I!R 1 W,000 BTU) TOTAL: -
Yes No
Willthe applicant tureWildleg occupantuseequipmemcodevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent hazyNou.air contaminant.as defined by the Bay Arca Air
Quality Management District? BOILER-COMP PHP OR 100,IX0 BTU)
Yea EgN.
havereadthehua teriai.requlrementsunderChapter6.95of BOILER-COMP 100,000 BTU) ��� �.44]Q�
the Califomh Healthk code,Sectiom 25505,25533 and 25534.1 11``s9
u erst dthat if Ne doesnot rently have:tenant,that,,is my NEW RESIDENTIAL MEClL SQ.IT.
cap° cyton yt o pant requlrcmenta which must be mart +'
prior
.an a nifl sof panty. CI4 Asa Of P +yIIQ
_ UpC
razed encWar,
TOTAL: ISSUED BY_�_ NL
OFFICE COPY