20656 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
R199AQ13 �RtlalEluDGE 14VE U,S�JIU 6 LJ 20656
1wlncrs me: one:
�TEWK%LI 447-05 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: u " APPLICATION / PERMIT l
SBUILDING-ELECTRICALPLUMBINC-MMHANICAL CATEGORY CO �jQ te En neer. p,X�ll '7 L No: DLJ" ar(r K n' QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PER ITISSUANCE ❑ 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affbm that l am licensed under provisions of Chapter 9(remmmc APPLIANCESRESIDENIAL JOB DESCRIPTION
Ingwith Section 7000).(DtA.i..3ofthe Budneuand ProfeW..Code,and my
Bons Ie in fou ford and affect. PANELS
Liuns Clam Limo IN.X1
Date Contractor
ARCHITECTS DECLARATION 201-IODOAMPS
a0 O I understand my p)am shall be used w public records. OVER IMO AMPS SQ.FT.FLOOR AREA S/SQ.Fr.
Licensed Professional SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION
Q � � �
G+],� SP[CNLCIRCUIT/MISC
t"' owing rasorm that I Sectio mexempt from the Contractor's License Law fort he
o county
reason.(Secrion7m15,Buslnem and improve, Code:h, city or
Og;� Y t7 TFMP.MEfEItORPOLEINST.
P� c.untywhkhrequlresa permit lomnslruct,altep Improve,demolish,orrepair
q anystmu repdortolmimuame,alsomquimstheappuantforsuchpermltto POWER DEVICES
rY1 Bm a signed statement that la is Hcensed pursuant to the provisions of the
OwI. Contractor's License Law(C)apter9(cammeneingwith Section 7000)ofDivi.
f,�0"J don 3 ofthe Busmmsand PrefemloreCode)orthat he b exempt therefromantl SWIMMINGIVOL ELECTRIC /• VALUATION
O.•3] the basis for the alleged exemption. Any violation.f Section 70315 by any OUTLETSSWITCHESFIXI'URES
applicant fora permit subjects the applicant to a civil penalty of not rmrc than CEJ
R�qundred dollars(gSfM). NEW RESIDENTIAL ELECTR SQ,FT. SIDWFS TYPECONSTRUCTION
L I,as owner of the property,or my employees with wages as their sole
7Q mmpenuHon,will dnfhs wok,and thestrvclure is cut Intended or offered for
❑ ul=(Scc.706y Bwlnessand Pr°femiow Codc:TMContracoe.Llcetae Law
$Q docs not apply 10 an ownerof property who builds crlmprove,thereon,and OCC.CROUP RIS.UNRS
who d.essuch work himselforthmagh his own employees,provided that such
Improvements arc not intended or.ffered for sale,ILhowevegthebulldingor T IAL:
improvement b=old wilhin.ne ycarofcompletmry the owner-build erwlll have
rden of pmving that he did not Wild or improve for purpose ofwh). QTY. PLUMBINGPERMIT FEE FLODDZANE API
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANC
«ora to construct the project(See 7074,Business and Professions Code:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&V A
Wilds or Improves thereon,and who contracts for such Eta"with a
c ador(s)licensed pumuant to the Contract 'n License Law. BACK FLAW T. C. FEE SUMMARY
I am exempt under Sec�- B k P C for this meson
NSFLOOR, F,A SANITARY Y N
• Owner Date —� RECEIrT0
WORKMAN COMPENSATION DECLARATION SCAOOLTAX Y N
❑I hereby alflrm that I have o certificate o consent to opytnmre,or RECEIPT X
3800,L teofWorkers'Compensationlnsuranceora cettl(led mpythemof(Sac. G AOUTLETS PARKFEE Y N
RECE3800,Lab C.)
Pollry X DING DI N
Company GAS .SYS V' 4(RA) BUILDING DIVISION FEES
I ICertiBV copy b hereby fumished. C S /IN LWAS'TE INTERCEPTOR PLANCHECK FEE
Lr�J•CertlRed copyb(fled with the city Inspection division. J
CERTIFICATE OF EXEMPTION FROM WORKERS' GR PAID q/—'J'QO �_(r'
COMPENSATION INSURANCE SEWER-SANITARY-SICIRM EA 2lXIFT Date RC[mi t#'jPR
(Thbaection need not be completed lithe permit b forooe hundred dollare
(57ifythat
mnn
I ncei(y atthe performance of the work for which this permit Is issued, HEATER W/VENT/ELEM ENERGYFEE Yved, N—
I aha 11 not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING eI 1j
Workerv'Compenwti.n laws o(Call(omb.Date PAID 1
Z Z Applicant NEW RESIDENTIALPLMS._SQ.7. Date Remi t#
Z O NOTICE TO APPLICANT:If,a Bur making this Certificate of Exemption,you
Fshould become subject to the Workers'Compansati.n proWions ofth.Labor TOTAL:
(A Code,you moat forthwith comply with such provisions or that permit shall be
deeed voked. BUILDING 00 O
W
mreG CONSTRUCTION LENDING AGENCY SEISMIC FEE 4,C2j
I herebya(Ormthat there is a construction lending agency for the perform- ELECTRIC FEE
Z ance ofthe work for which this perm)4b bsued(Sec.3097,Civ.Q TOTAL:
V O Lender's Name /L/ PLUMBING FEE
LL F Lendela Addrem "/ QTY. MECHANICAL PERMIT ME MECHANICAL FEE
OW l coodylhat l have read thisappl ati.nand abouthattheabovalmormation
6 bmrsed.l dgree to comply with all cityand muntyorchrancesand datelaws PERMIT ISSUANCE FEES PAID:
Y W relating Wbullding mrstrudkx%,and hereby authorize mpresntatives o(thts
I— Z cityt.enterupon theabove.mentloned property for Inspection purpose. ALTFRORADDTOMECH. Date Re[ei t#
— (We)agree to save,indemnify an d keep harmless the City.f Cupertino
against liabilities,jodgmonts,codsand expense,which may In anyway accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'consequenceaga Wt sal'City in consequence of the grant Ing of thl it
3-qo AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Sigbadoe.f AppBnsnt/Contractor Data Eg1AUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSU R Ii
Will the applicant or!inure building occupant store or hand lc hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,C hapter 9AZ and the Date RC[el t#
Hes lth and Safety Cod on 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
RYeno
ill the applicart;;7ulline Wild Ing ocmpant use equl pment or devices V EMILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardoos air contamW nm as defined by the Bay Area Air
slaty Mznagcmcnt Dbt' 7 BOILER-COMP DFP OR 100,000 BTU)
Yca N7
have mad theF a artaterials requirements under Chapter 6.95 of BOLER-COMP(OVER 100,000 BTIJ) JUL 311990
the California Health k Safety Code,Se=tiom 25505,25533 and 25536. 1
understand that if the building dace not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which moat be met /� .L
poor uancet ofOccu
of. (;I P``l ('U,CflrtiDP
Owner. lhodud agent Date ISSUED gY: V V
TOTAL
OFFICE COPY