20712 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
H.iidh,Addm,a:Building Project Identification ZL �j - -- PERMIT NO.
CAl 20712
wvr``e sane: one.
ooHA
N2 MpO.C�p(O.by'k,C� CITY OF CUPERTINO-BUILDING DIVISION
contractor'.Name: I�Lee.No- APPLICATION I PERMIT
ti 3;60 BUILDING ML TRICALPLUMBINC-MECHANICAL CATEGORYCONTROL 10�
Archkect/ neer. ��,,yy �� Lk.Na
y'G
Qrr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreac 'Aj. - �,a
PERMITISSUANCE ' = N 'N --I�p
SLUG EL�j PLUMB
LICENSED CONTR under provisions
COB ILIO
IhthScrebyion7OOO)afform fDimsimaedue BuemssandP fehoer9(mmmm< APPLIANCES- L JOB DESCRIPTION _ rj
Ingwlth5ect1on7000)of Dlvisfon3ofihe Buslneesand ProfeWormCode,and my tTC�JrL1VYa
license is in full force effect r5 L .// PANELS C{�..+(�` , ,1 _
Limn — Lk.N T 0.4�4C2, 5( O W L-�
Contractor Gs
ARCNITECI'S DECLARATION 201-1000 AM
c4 7 I understand my plans.hall be used as public records. OVER 1000 SQ.I FLOOR �5/SQ;Fr.
Licensed Professional9GNSELECIRICAL IN. sub ��'yT -cal
< OWNEReBUILDER DECLARATION
I"n SPECULCRCNT/ 15C ,sIII�T 6
z F'�4 [hereby aftlmnthatlam exempt(mmthe Contractor's License Law fareha
o following reason.(Section 70715,Busman and Professions Code:My city or
P,ZI"' cmntywhichmquUsapermitwcomt dalter,improve,demollsh,orrepair IEM[s.METFR OR L
q� < nysuucrumprlortoihi ancqaLwrequbelheapphuntforsuchperMtto �•�
'N O�U file a signed statement that he 1.licensed pursuant to the provision of the POWER DEVICES
EQS µµ Contrad.e.License Low(Chapter 9(commencing with Section 7000)of Dlvl- "G POOL ELE
slon3ofthe Buslneuand PmfewWm Code)orthatheiscumpttherefmmand VALUA7]QjJ )
Q the basis for the alleged exemption. Any .violation of Section 70715 by any, F
D.D. 7CHESFI%TURES I f
ro applicant fora permit subjects the applicaottoa civil penalty of not manothan
ca OUTSIDEFEES
five hundred dollars(55110). EW DENTIAL ELECTR SQFr. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and therm seen b not Intended or offered for
Oask(Sec 7064,Business and Profemlon Cade:The Contractors License La
$ does nnapplytoanowvrofpmpertywho builds orlmpravest rem,anwhod S'
whom nan1samwork Mmeelforthmff.redown employees,pr avid that
aUOCC.GROUP RES.UNRS
Impmvementa are not Intended oroffered loruk.IQ hawevegthe TOTAL s
Impmvementbsoldwlthlnovyearofcomplctiorythe owner-bulloe 1
thg,¢trden of proving that he did not build orlmprovefor pu o .). UMBiNC PERMIT FLEE
LI L as owner of the property,am exclusively mntraRIng w h sed FLOOD ZONE APN
contractors to construct the project(Sec.7014,",uslness end Pro! Code: PERMIT NCE
The Contrudoes License Law dm net apply to an owner o(p who ALTER-DRAIN k VENT-WATER MA)
Wilds or Improve thereon,and wl.contnab !or sash project Ith• FEE SUMMARY
cgB(Pctor(s)licensed pursuant to the Contractor' License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B k P C for thio amn
• DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data *ENER(:;f
EIPT#
WORKMANCOMPENSATIONDECLARATION E7X.IVRES PER TRAP SCHOOL TA)( N
❑I hereby afRrm that I have•cer00ote of consent to sell-Insure,ora IPT N
certlflcaleofWorken'Campematlonlnsurance or a cartllkd copy thereof(Sec. GAS FA.SY511➢.1- N
38011,lab C.)
Policy N IPT N
GAS EA. 4
Com ray DIVISION PEES
�Certlfled copy bhereby famished. GRFecF/IVDU E
Certified copy 0 filed with the city Wpectbn division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP
COMPENSATION INSURANCE SEWER-SAND'ARy-yTORM FARecei t# "J"I'Fa�
(Thlssection need out be Completed
if pertnit V(crone hundred dollen
(8100)orless.) WATER HEATER W/VFNT/ELECTR N
I fi er le that ta the per(amuncaaf the work farwhkh thin permit Is heard,
1 shall nm employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID '6 (y�
z,Z Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t# ilSc
Z O NOTICETO APPLICANT:If,after makingthls Cenificate of Exemption,You
should become subject to the Workers'Compenation provisions of the Labor TOTAL:
N Code,you must forthwith corry"th such provisions orthis permit shall be 3.0 �'
W j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY S=9'-L&I
Ibereby.fil that there h a construction lending agency for the perform TOTAL: p / ELECTRICFEE (O ,G, E
M Z now of the workfor whkh thin permit h Issued(Sec.3097,Cle.C.) { tis
V O Landare Name 'PLUMBING FEE qG1
H Lenders Address QTY. MECHANICAL PERMIT FEE S
OW Icertlfythat i have read thhappBcatWn and stalethatthe abovelnfomWlon MECHANICAL FEE
IL hcoctree
rm .I agto comply with all city and county ordinances and state laws PERMIT ISSUANCE 1ZM FEES PAID:
�.N relating to building construction,and herebyauthoriu expreartativesofthb
1•` city to enter upon the above-mentioned property for Inspection purpose. ALTERORADDTOMFGH.
? (We)ager to uve,IndemN(y an d'keep harmless the City of Cupertino Date Receipt#
V against liabilities,pdgments,mrtcand expenses which may In anywayamue AIRHANDUNCUM7(TO10,000CFM) SUBTOTAL• a
apleatuld Citycon equermofthegan this Ten
it.
AIR HANDLING uNrr(OVER ID,IDo CFM) CONSTRUCTION TAX 7
CONSTRiCJJp[yTAX P�6ID: (�' a
Signa eofApplicant/Contra r Date IXFIAUSTHOOD(W/DI1CT) 1[[�' (� tP Z
Hot
AZARD MATERIALS DISCLOSURE s0
Wilitheapplkantorfu buildingoccvpantatore or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date ecel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Iealth and Safety Cade Section 25532(•)7 HEATING UNIT(OVER 100,000 BTU) IrOTAI
RYon No
ill the applicant or lure bu lleing occupant use equipment or devices VENTILATION FAN(SINGLE RESID) DA'Z'E
which eManavrdouaircontaminants nla as defined by the Bay AAir
QualityManagement air
District?
BOILER-COMP pFm OR 100,000 BTU)
Yea ❑No 1 A N
(h ave read the bazaMaus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) / �19
�
the Californla Health&Safety Code,Sectlons 25SO5,25533 and 25536.1 v.
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. Als
responsibility to notify the occupant of the requirements which must be met
\ prior to Issuance ora Certificate of Occupancy.
e �I!
I �
Owner or authealzed agent Data /'•` ISSUED",
TOTAL: D b
OFFICE COPY