24118 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'.RldentlflntlonPERM1T
B2OS4b Nq, 4118
ullding Address: ,
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1 a Wv. - CITY OF CUPERTINO-BUILDING DIVISION
Con1fcho aName: Lic No APPLICATIONJ PERMIT
Ard en/Engineer. Llc No: 7
BUTLDINGD.EC C BINC-MECHANICAL CATEGORY CONTROL, 70�(
C 1—1 10(o OnELE R C PERMIT �E BUILDING PERMIT INFO
Address $54 HIJjVjaL,,rer L11 _".C T WNCE1 .
LICENSED CONTRACTOR'S DECLARATION C
Iherebyafflrmthatlamlkenaedunderpr i.lona.(Chapter9( S4e. Ik4 4A�ANCF&R2SIDFNT1AI, 1OBD
Ingwlth5ectlon 7000)aI DlWslan3ofthe Buelnasand Professions e,A
- Iimnse I,in full force and effect. y PANELS )))
Lianx Clam Lk.a SO /1 _� asl 'ww O 4e-
Date
C /
Date Cantnctar /~`}~–]',(`yam E'v`
ARCHITECT'S DECLARATION 7m-1000
070, Ilujurstand my phru,hall be used. blicremNa. V' I I'S SQ.FT Fl, AREA S/SQ.Fr.
Lice
ed Profe oral NS ELECTRI
6 OWNER-BUILDER DECLARATION SPEC CUT/MISC •' (J $' Q.� '
L, Thereby affirm that Am exempt from the Contractors License Lw for the - C/ / �Q �a
Zo o following rcmon.(Section 707LS,Business and Professions Cade:Any city or P.MEffRORI'OLEINST. �- l a �a
rrmtt@ county which requires a permit tomrutrutl,alter,improve,demollsh,or repair
40 any etrocture pdorto its Wuance,abo requiralhe apphcantfwauch permit to POWER DEVICES 9'
LWVS file a signed statement that he b Ikxnend pursuant to the provLaloru ofd
u,In Contractors License Law(Chapter 9(commencing with Sect 1..7000). vi- t
30 SWIMMING POOL ELECTRIC
slon3'ofthe Buslnessand Prnfesslora Code)orthat he b exempt them mand VALUATION
E. S the basis for the alluged exemption. Any violation of Section 7071.5 by any
OSS 117i.E'ISSWIIC}16FIXTURFS
applicant fora permit subjects the applicant to a civil penalty of not morethan O a 6
{q� five hundred dollars($SM.
'9-I-.•"' I,as owner of the NEW RESIDENTIAL ELECrn FT.
Z ❑ property,or my employees their —SQ.Fr. –�fYl'E N TION
t,6 le&c. DAK B.Ai.will do e work.Lndlhes Code:Thee is Contactorort Intended or License
Lau, I
P D dote(Sec apply to a now and Pro(miam Cade:The Contractors Clams law G
r3$ whodoes ev uch torn owner of Property lf rough who b ilds amp]yeas,pres ovided
and
whodoements am not intended or offered
his own emp,however,
he building
or
hat such A
improvements notintended
s.r.1co fee sale.ILhowwep deer ill have T
improvementbsold within oneycarafcomplellorythn owner-bu0derw0l have
thij,Ilu Nen of proving that he did not hu ed or Improve for Purposes,of sale.). QTY. PLUMBING PERMIT FEE
L as owner A7tr the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to cowwct the project(Seo 7091,Buslnm and I'rafmlora Code: 1 11
'
The Contranore License Law does no apply to an owner of property who LTER-DRAIN k VENT-WATER(EA)
build$or Improves thereory and who contracts fee such pKajects with a
R(�actor(.)Rmnsed pursuant to/he Contractor's Lianx Law. FEE SUMMARY
Cg
Lj I am exempt under Sec. B k�P C for this reason AIX FLOW PROTECT.DEVICE
OUTSIDE PFC—S
Data' .
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N- RECEIVE B
WORK MAN COMPENSATION DECLARATION FD(.NRGS PER TRAP SCHOOL TAX Y N
Of hereby affirm that I have a artiflrate of consent to self-Inwre,or a RECEIPT'M.
ourtificate.(Workers Comperuatlon]murana we certlfled copy thamuf(Sec. pg.[A SYS77Tt•i INC.40ITILLTS PARK EEE Y N
3800,Ub C.) -
Pollcyq - GAS EA. RECI:IPPB
Com any - BUILDING DIVISION FEES
E]Certmed copy b heed with im cit. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E]Codified copylaflled with the city inspection division. �j
CERTIFICATE OFuEM!"FION FROM WORKERS' GREASETRAP PAID;R 6_ �4L
COMPENSATION INSURANCESEINER-gp pRY SInRM EA 100I•T, r' Date �NyCtt`=fl 1—N
Rhieaection need not be completed if the perodt b forox hundred dollars
(8100)orlmd WATER HEATERW/VFNUELECTR ENERGY FEE Y_ N_ O3•m
l ourtifythat to the perfartrena.(the work(.,which this pemdt 1.Weed,
I shall not employ any perwn In any manner so as to become subject to theATIR STEM/rnEAnNG - (I l L
Work m Cons
mpeation Laws.f CaIfomla. Date PAID
Q Z Applicant RESIDENTIAL PLMB._SQF7. Date R 1 tH
Z 0 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
I" should become subectto the Workers Compensation provisions of the Labor TO AL;.
fA Code,you must forthwith comply wlthsuch provbloraor this permit shall be - ,
> deemed revoked. ----BUT 0 0.ry
a G CONSTRUCTION LENDING AGENCY SEIS
I hereby afOrm that there la a construction lending agency for the perform
Lawork fola097
r which this permit Issued(See 3 ,Civ,
0 L
nd
V Lander'.NName
.LL F Landes Addre.a QTY. MECHANICAL PERMIT_ FEE M HA LE
O W Icertify that l have mad thlaapplicationand aatethatthe above infornmian
1 hcomect.I agree to comply with all city and county ordinances and slate lawsPERMITISSUANCE 1 FEE 1'Q
>_ W relating tobuiliing construction,and herebyauthorlaerepresentativesofthb (\Y—
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. DaIC RCcei IN
— (We)agree to save,Indemnify an d keep harndess the City of Cupertino
agalrat llabilliMe,jLdgments,corteand expenxa which nay in any wayaarue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Against said City In consequence of the granting of this permit.
AIR HANDUNG UNIT(OVER 10,000CFM) *� CONSTRUCT NTAX
Signature of Applicant/Contractor - Date EXHAUST HOOD(W/DUCT) CONSTRUCTI N TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Will the applies At or future building ocapant.tore orbendlehaaardous HEAIINGUMT(TOI00,000 U7Lj r� Date. R t _
nuted.l.,defined by the Cupertino Municipal Cade,Chapter 9.1$and tM1e
Halth and Safety Cor(!Acalon 75532(a)i HGTING UNI'T(OVER 100,000 BTU 'I' T
F1 Yea DCu7 N0 _
Will the applicant w turn building onvpant use equipment or devious VENTILATION FAN(SINK RFSID) ISSUA DATE
which emit hazardous air contaminants a,deflood by the Bay Area Air
Quality Management W ct7 BOILER-COMP OHPOR 100,000 BTU
4 Yes I�No D
have ad thelth&Sfn( ma k Se requirements one25505,255 3 aChapterb.95 of BORER-C'ONP(OVER 100,000 BTU) 'P A ct
� the Californianla Health&sLlety Cade,$ectlora 75505,$533 and 255]9.1 ,
understand that[(the building does not currently have.tenant,that It is my NEW RESIDENIIALMEC1. SQT7.
responsibility to notlly the occupant o(the requirements which must be met (1 y
pri. Issuance`f.Cedifiateof Occupancy. / 1
Ownerorauthorked.goid Date Y
- ISSUED BY: f 9L�O
OFFICE COPY