20703 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ea mendf cagon PERMIT NO.
8.1111.g Adare.a: � 20703
1bG3o S . CS/A.+ �� CIPC ? ✓ `15D/
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Anlq Opt-His 9 3124 CITY OF CUPERTINO'BUILDING DIVISION
Gan' ar CI� "{Lk.N fG uG.N APPLICATION /PERMITall
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W BUB-DINC-ELECTRICALPLUMBINGTEGO
MECHANICAL CARY CONTROL Y/_bq ?
Itttt/Engineer. ,^/n' V
AeRL�
LICENt
Addrces21 QTY ELECTRICPERMIT FEE
BUILDING PEROMIT
INFO
xc
SD CNCPERMITISSUANCE
LARATI N
I hthSb lfb7m00tDb)aotflDalmvli.3d(thi.Bwr.i n..O nao(Chapter9(mmmene AAPPLIANCES-RESIDENTIALlice.seei.f.11J .naGfect, dProresdonaCcellincimy PANELS
Lic.8 ]OB DESCR)R'
f1ON
a
C�Oats Contractor J.J O•xl��I xa�vaL./LIMY- 11
AiCHITECPSDEC RATIO 201-1000AMP5 l (J`
�pp�uu mOQ I la my pia else u as public rerord. OVER 1000 AMPS SQ.FT.FLOOR A��R--E//..Aaa $/S'�Q..FT.
Ltee, a tonal SIGNSELECTRICAL Z 7 I
6 OWNER-BOLDER DECLARATION SI'ECIALCIRCOT/MLSC t
2 F' � Iherebyaflrm tlutlamexemptfromlhe Contractors License law(or the
O F following reason.(Section 7031.5,Buslneu and Professions Code:Any city or
Py comtywhlch requbesa permittnmmtwct,alter,Improve,demolbh,urmpalr"TEMP.METER OR POLE INST.
any strocturctatemethat he 1,licensed pursuant
to thetfaauion,of
pOWEIt DEVICES
els a signed statement that he b licensed pursuant to the provlelom of the
Contractor.License Law(Chapter 9(mm .d.gwith Setllon700o)ofDlvl-
vi S sion3ofthe Busi mmdPr-f—I.m Cad ).rthat hebexemptthemfmmand SWIMABNG POOL ELE CO< the bast for the alleged secure a Any ttG atlon or Section 7031.5 re any OUTLETS-SWITCHESFI ES _I J SappllunHorapemdt$SM. she app8csntroa civil penalty o(notrrorethun ff—VALUATnIOlb
C
five]1,as ed owner of
( 5M. NEW R ENIT
�n ❑I,asowneror theework,aormy employees with wages Ilanrot —�fT• [S 71TE CONSTRIX:TION
compensation,c70K wuldolbe work end thesC dere b not Intended or offered for
O
sale(Sec.70Cy Business andlPmperty hobuiThelds Contractors Llama Law
daea not apply to an owner olproperty who builds or lmprovm thereonand
whodaessuchworkhtm lforthmughhlsownemployen,provided thatauch OCC.GROUP RES,UNITS
Improvements are not Intended oroffered forsale.If however,the buliding m TOTAL:
bnprovemembwldwltMnoneyearofcomplNioo,theowner-buBeb di have V
the bumen o/pmving that Ae did out build or Improve for purpose ofsalaJ- QTy, P MIT FEG
�J L as owner of the property,am exclusively mntracting with horn ad WOOD ZDNE AIN
rontnctan to ronstmctthe project(Sec.7094,BuaNen and Pro(mlons Code: a P ANC ,
The Contractors Llan.Lsw does net apply to an owner of property
Wild.or improves thereon, and who central,(or each pTofem wit a AL IN& -WATER
ro actor(.)licensed pursuant to the Contractors Lk Law. FEE SUMMARY
I am exempt under Sec B k P L (or fhb rtaw 9A T.DEVICE
OUTSIT)"FEES
Ow r Date D NS OOF,AFkA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT M
l I hereby.1111.that I have•arUBate of consent to self-Iowa,ora PERSCI1O0L TAX Y N
artitlate o(Worken'Compensatlon lmuranceaa certified copy thereof07ec. RECENT N
380D,Lab G EA. STEM-1 PARK FEE Y_ N_
policy N 7 RECEII'P N
Cre �"� A6 EA, d(EA BUILDING DIVISION FEES
�Cedi ied ro by tumt ed. GREASE/W INTERCEPTOR PLANCHECK FEE
Certified ropy b filed with the city Impaction division.
CERTIFICATE OF O(EMPFION FROM WOR KERS' GREASE PAID_7'Ip�O
COMPENSATION INSURA14CB
(fhbsecticormil not W eempleted Btheperodt 6(oronehundred dollars SLIVER-SA AR RM EA. Date Recei t#
(5100)otifyth ENERGYFEE Y_ N_
Iartlfy that In the performanaotthe wak farwMrh this permit isbwed, WATER Iff.A W ENT/FlFGTR
l.hall not employ any person In any runner w u to become wb ed to the `7 •! f/
WATER SYST[M/TREA NO
O Workers'Compensation Lawsaf California.Date PAID
Applicant
Z Q NODCETO APPLICANT:10fter making this—C-91—of Exemption,you NEW RESIDENTIAL PLMB. :n,El', Date Re i t#
Workers'F should become subject to the Woe 'Compensation provisions ofthe Labor t
pl
Code,you=at forthwith comply with such provlelons orthb TOTAL:
permit shall be
W > domed revoked. BUILDING •O4
(LO CONSTRUCTION LENDING AGENCY M
L_
= Ihercby a(flrtnthat theretaromtwctlan leadingagency for the per(orrry TOTAL:
once olthe work forw�kh/qts 11 issued(sec,3097,Civ.C.)
W 1
LL 0 lender.Name
LLF Lender'.Addre.a QTY, MECHANICAL PERMIT ITE EE a
O W Icertilythatl have aadthlsappliatlon and matelhatthe above ln(ormatlon G'�
4 tcomxt.lagrccto comply wkhallcttyand muntyaminaam and statelawa PERMITLSS'UANCE 11c�
} N relating to building mnstwRion,and hereby.whodze representatives o(this 2
H U) city to enter upon the above.mentioned pmperty(a inspection Purposes. .0. ALTER OR ADDTO MECH. (�
(We)agree to save,Indemnify an d keep harmless the City of Cupertino t Receipt#
V agaWtBabilltin,judgmen metsandexpenseswbkhmaylnanywa .arae AIR HANDLING UNIT(TO 10,0D0CFM) UBTOTAL•
jag City In con na o renting of this pet
471 AIR HANDUNG UNIT(OVER 10,fDOCIM) CONSTRUCTION TAX
o pp am/Con ractor Dat pxxnuST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARD MATERIALS DISCLOSU Etheappll nt or future uitcing occupant store or handle havardous HEATING UNIT CIO lODODO RTU)la.defric by the Cupertino Municipal Code,Chapter 9.12,and the Date ReceI t#
Here lth a rad Safety Cade ton 25532(a)P HFATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yn No
Will the applicant forum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemithamttlous Ir mnleminantsas defined by the Bay Area Air
QualltY�mgemnnt Di BOILER-COMP OLIN OR 10,000 BTU) lr
No d
4b.vereadthehaz o mate cls equirement under Chapt¢r 6.95 of BOILER-COMP(OVER 100,000 BTU) p �(]
the Calllarnla Health Safety Code,Sections 25505,25533and 25539.I 9a !# N �x7JO
undentaM that l(t building does not comnily have a tenant.that It b my NEWRESIDFNTIAL MEIN. $QFI. I r
respomibility,to notify the occv a oItherequ ment which must be cost
priorlo da Certifloeu cups
041 at 0i
WWUt
Owner a re a t arc ISSUED BY: "✓
TOTAL:
OFFICE COPY