20469 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LIMES — USE BALL POINT PEM ONLY
Building Project Identification PERMIT NO.
Building Address:
kIND� �,5 � �. 20469
wners arre:. one:
�. Ca.Ya.. &�IrS�•l 2,i3-69% CITY OF CUPERTINO-BUILDING DIVISION
contra"ar'a Npame: Lm.Na: APPLICATION /PERMIT
CLI RT(N0 L L)N& 6 B BIRLDINGELMTRICALPLUMBING-MFOHAMCAL CATEGORY CONTROL It -
Archi /Englnar, Lie.No:
QTY ELECTRICPERMTT FEE BUILDING PERMIT INFO
ddrcse: _ ❑ ® ❑
Q064 A LE PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that son licensed under provisions of Chapter9(ammenc- APPLIANCESRESIDENTIAL • JOB DESCRIPTIONingwith Setlion7ODG)ofDivisim3ofthe Buslneuand PmfusionsCode,and my s,
lire..is In full force and effect g
Datejj PANELS
Lire..CIassC^ LiffX ate" 20 '
� .
CantractoLa!TO 2DO AMS
ARCHITECI`S UECLARATION 201-IOOOAMP5
IXO ZOC I understand my plana shall be used u public rerords. OVER 1000 AMPS SQ,FT.FLOOR AREA $/SQ.FT.
(f Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIl2CVIT/MISC
z . 1hereby affirm that I am exempt fromthe Contractors License Law for the
o qqqq following recon.(Section 70315,Business and Professions Code:Anor
�$ county which requires a permit toconaruct,alter,improve,demoWh,ocity
rrepair TEMP.METER OR POLE INST.
°4 3 anystrutiure pdortolts issuance,also mrylreatheapplicantfor such perenitto
g 6 file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
O k Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
3 OSWIMMING POOL ELECTRIC
slon3Ofthe Busineuand Professions Cade)orthet helseaempttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any >--+
G
applicant for a permit subjects the applicant to a civil penalty of net more than OUTLETSSWITCHES-FTXTURFS
O Ove hundred dollars($500).
ML owner of the property,or my employees with wages as their winNSW RESIDENTIAL ELECTR_SQ.FT, STORIES TYPE CONSTRUCTION
compensaHon,wBldothe work,andthe structure la not Intended or offered for
O ssle(See 7044,Buebeaa and Professions Code:The Contractors License Law _
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP AFS UNITS
a who does suchwork himself or through hisown employees,provided that such
improvements are not intended or offered for sale.If,however,the building or TOTAL:
improvement is sold within one yearofcompletion,the owner-buRderwill have
t1j!ytden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE - FLOOD TONE APN
LJ I,as net of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7644,Business and Professions Code: �Q
The Contractor's License Law does net apply.to an owner of Property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptojects with a FEE SUMMARY
egpjfactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE LI I am exempt under Sec B&P C for this reason
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner^ Date - w^' SCHOOL TAX Y_ N RECEIPT
WORKMANCOMPENSATIONDECLARATION
IMI I hereby affithat I have a arti(4ate of consent to. FIXTURES.PER TRAPyr
1(-Insure,or RECE PT j7-
-certificate Of Workera'CompeouHon leursheeoa certified cepythereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARKFEE ' Y N
3800,Isis CJ 'r r� p/1 p'+) RFCEET X
'-. Po11ryX GAS EA.SYSTEM-OVER `
Com BUILDING DIVISION FG[g
[P Certified copy is heed with t e iid. . G / As _ TO PLANCHECK FEE
Certified copy V(Red with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' TR^I'I�/I- - PAID '
COMPENSATION INSURANCE SEWER-SANff.'ARvY'i eA'' Date Recei t#
(This section need not be completed lithe permit u forne ohundred dollars
$100)or leu.) WA7Ij1.ERW / ENERGYFEE Y N
I mnify that 1.the performance of the wok forwhich this permit is issued, .f —
I shall net employ any person In any manner°o as to become subject to theWATIR SYSTEM/TREATING '1
Workers'Compensation Laws of California. Date PAID
-
Z
Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
O NOTICE TO APPLICANT:[(,akar making this Certificate of Exemption,you
Hshould became subject to the Warkem'Compensatloi provisions ofthe Labor TOTAL:
Ln Code,you mu at forthwith comply with such provisions orthb permit shall be a(/O
W > deemed revoked. BUILDING '
CL 73 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them b a construction lending agency forthe perform TOTAL: ra�s ELECTRIC FEE
7 Z anre of the work for which this permit ls issued(Sec.3097,Civ.C.) ye
(-) 2 Ie.ders his PLUMBING FEE Pe 4
LL !_ Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I artifythat l have read thleappliatbn and statedatthe above Information
1' Iacomm,I agreeto comply with all city and county ordinances and date laws PERMIT ISSUANCE FEE$PAIjT.
} W relating to building construction,and hereby authorize representatives ofthi°
Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Reeei t#
V — 6Ve)agree to save,Indemnify an d keep harmless the City of Cupertino P '
against liabilities,judgments,ends and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sald Cid•in corrJJ��cluypasrr f the grunting of this permit.
o' �— AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
mit-'1-90
Signature of AppB or Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS EXHAUST MATE RIALS DISCLOSURE
Will the applicant the future ruin ngompantode,Ch pierhandle hazardous 7{FAIING UNIT(TO 100,000 BTU)
material Municipal Cole,Chapter9.12,and the Date R2Ce1 t#
Elcalt Yea Safety Cd Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑ Yes No
'- Wilt theapplies,
moo
building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DATE
which stet hazardous air contaminants as defined by the Bay Area Air '
Quality Management DlsMa7 BOILER-COMPP(HP OR 100.000 BTU) P
4We No
M1avenia Health&Safety
Code,materialsSe requirements 255nte5533 aChapter.1 of BOILER-COMP 100,000 BTU)
the
erstan tHealth&Safety Code;Sections25505,25533have
tenant,
II II(,�P 1 X(gn.`L4iP4"dB
understand that if notify
thfy the occupant
not the
menta which
that it met NEW RESIDENTIAL MECH. 'SQ.FT.
responsibilityissuance
of a Certificate
tccupa requirementswhich must be met
prior uan=sofa rtte of Occupancy. (Ipg71M(f]I,;w,.+)rt,vs
Owner roora thor d WnI Door - TOTAL: ISSUED BY:
OFFICE COPY