23778 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PFItNIIT NO.
Building Ad l L-t se� � . � 23778
ame: APPET!= A A
CITY OF CUPERTINO-BUILDING DIVISION
Contnctor'e Name: Lie.N. APPLICATION / PERMIT-415(479 C�
BUILDING-ELECTRICAGI'LUMBINGMF HAMCAL CATEGORY CorO /W--j—
Architect/ neer. Lk.Na (•/L/
M QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: tsl ; $T� A...� FERMITISSUANCE �Dv eyA� .�yy/
LICENSED CONTRACTOR'S DECLA ATION W IL�J
I hereby affirm that l am licensed under provisions of Chapter 9(mmmmc APPLIANCES-RESIDENTIAL JOB DpSCRB'TION
Ingwlth5ectlon 7000)of Dlvtslon3ofthe8uslnessand Prolessiom Code,and my
license is In fuBI and dfect. PANELS
License Cls
Cmdct �f1
Date oer. or �•-�V
RCHITECTS DECLARATION 201-1000AMPS
Z I understand my plans shall be used as public record& OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
{y O
ll�j Licensed Professions] SIGNSELECTRICAL
i6 c. OWNER-BUILDER DECLARATION SPECIALCR;CUIT/MLSC
7'• 2 1herebyafOron bat lam eaemptfromthe Contractors License Law for the
o following reason.(Sedlon70315,Busineseand Professions Code:Anycityor
O Z I^19- TEMP.METER OR POLE INST.
r� � cantywhich requiresa pemdtromnstruct,alter improve,demolbh,orrepalr
Ov anystructure priorto its Mssance,aborequirestheappllcant for such permit to POWER DEVICES
file a signed statement that he,b licensed pursuant to the provedorw of the -
40�
Contractor's License Law(Chapter 9(commencing with Section 70(())of Divi- SWIMMENGPOOLELECTRIC
sion 3 ofthe Business and PmfessioresCode)or that he b exempt therefromand �AL
r
M
yd the basis for the alleged eectsth on. Any tviolationdel of Seaton 7m L5 by any -
applicant for a permit subjects the applicant toa dull pemltydne more thin OUTLETSSWITCHESFIX[VRES
five hundred dollars($500). NEW RESIDENTIAL ELECTR
?fin ❑I,as owner of the property,or my employees with wages as their sole —SAFE STORIES TYPECONSTRICTION
< mmpenmtion,will clothe work and thestmcture is not intended or offered for
O sale(Sec.706;Business and Professions Code:The Contractors Llceme Law
does not apply to an owner of property who builds or improves thereon,and
who devasuch work himself crthraugh his own employees,provided that such FIP5
Improvements are not Intended oroffered for sale.If,however,the building m TOTAL:g
Improvement is sold within oneyearolcompleflon,the owner-buikierwili have
I Nen of proving that he did not build or improve for purpose of sale.). PLUMBING PERMIT FLOOD NE APN�
Lj{as owner of the property,am exclusively contracting with licensed Pp�D ISSUANCE
con scion to construct the project(Sec.7064,Businm and Professions Code: NW
A
The Contractor's License Law does nor apply to an owner of property who DRAIN AVENT-WATER(EA)
Wilds or Improves thereon, and who contram for such ptoiects with a
cpNTactor(s)licensed pursuant to the Contractor's License Law. BACKWPROTFGT.DEVICE FEE SUMMARY
OUTSIDE IT
LJ I am exempt under Sec B k P C for Nb reason
Owner - Data R ROOF,AREA,COND. SANITARY RECEB7 p
WORKMAN COMPENSATION DECLARATION ES PER SCI;OOL TA% Y N
❑I hereby affirm that I have a certificate of consent to self-insure,oraRECEIPT
M
certificate of Workers'Compensation lmuddece m a certlfled mpy thereof(Sec. .SYSTEM-]I .40UTLE1'S3800.LabC.) PARKFEE Y NPdl MCam any .SYSTEM_OVER ) DINEIPT 0
DIVISION FEES
�ny'ficd mpy is hereby furnished.Certified mpy b filed with the city lnkedlon division. /INOUSTRL WASTE I EPTOR PLAI`j:WCK&
CERTIFlGTE OF IXEMPTION F0.0M WORKERS' TRAP �COMPENSATION INSURANCEPAID j�,LQhbsection need not becomplcted lithe permit leforonehundred dollars SANITARY-STORM FA.2110 Remi If
(Sl(10)rtilyt.) HEATER W/VENT/ELECTR ENERC ,`'�'�Aa�,I artlfythat N the perfrmnceofthe wmk for which this permit Is Ls1sMI shall not employ any person in any manner so as to become subject to theWorkers'Compensation Laws of California.Date SYSTLM/TRFATING
O Z Applicant PAID 5
Z z NOTICETOAPPLICANT:H,after coking this CertBkatc of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date
should become subjed to the Workers'COnnoduatlon Provisions.(the Labor TOT
WCCN Code,you must forthwith comply with such provisions orthb permit shall be
> decrredrevoked. BU DIN 'E.2
EL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there i a mmtmction d(Secg agency for the perform- ELECTRIC FEE
0 Z anceof the work!car which this permit Is kuued(See 3097,civ.C.) TOTAL
LL O lander'swme PL
ly F andm'sAadrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE 33. cid
O W Icertilythatlhave readthbapp0otionand satetrenmeab.vend. do. 1 ,./�
(1 correac.lagreetocomplywithalldty andcounty orelinancesand sate laws \ PERMIT ISSUANCE $a4/ FEES PAID:
} W relatlng to Wilding construction,and hereby authorize rcpresentativea.fthls -
Z city Menterupontheabove-endedand property for Wpnct1. purposes. ALTERORADDTOMECH.
(We)agrx tosave,mdemity and keep harmie foe C,n.,C.pertm. Date Receipt#
.gal tBab tksjuelgments,oossandexpeesesw h yinanywayaccrue AIRHANDQNGUNIT(I'O10,000FM
C ) SUBTOTAL:
Inst corn uence. e granting of his p con t.
e / AIR HANDLING UNIT(OVER l0,000CF.V) CONSTRUCTION TAX
5'ansture of pliant/Contractor to E%I{AUSTHOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UMT(TO100,000 BTU)
material as defied by the Cupertino Municipal Code,Chapter 9.IZ and the Date Recei tN
Healthand Sefety Coder+--Sseitioon25532(a)2 HEATING UNIT(OVER 100,000 RTU) TOTAL: fV
❑Yes u
Will the applicant or future Wilding occupant use equipment or devues VENTILATION PAN(SINGLE REBID) • OO - ISSUANCE DATE
which emit hamm
rdous air ntamimnts as defined by the Bay Area Air
Quality Management Dlutrict7 BOILER-COMPOHPOR 100,000 BTU)
Pity.
LT p pa
4 ve /W 6J
ave read the hazard'(—I eo materials requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU)
the California Ftealth k Ssfety Coda Bectl.m 25505,25533 and 25536. I QCT 19
understand that lithe Wilding does not currently have a tenant,that It b my h•EWRESIDENTIALMECH. .FT 9Q(T�
responsibility to redly the
occupant of the requirements which=at be coed SQ /s79�
priortoiss anceofa Certiflcateof Occupancy. cll r
b Ur i:Urcr,f(.
Owner s authorisd agent pate
TOTAL: 3X.OD ISSUED BY:
OFFICE COPY