19741 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERMIT NO.
BlBdin% 'a 4A
/4/4q//vO Q Dk I 19741
1�Y^/II��ppam���e: .µ ,hone: A
10' CITY OF CUPERTINO-BUILDING DIVISION
Contractor.Name: Lie•N.: APPLICATION / PERMIT
Archlted/Engineer.
BUILDINGELECTRICALML;) BING.MFLHAMCAL CATEGORY CONTROL#
Llc.No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Address: 1 PERNITISSUANCE I ,Z,_f� ❑ l� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION l
I hereby afilm that l am licensed under provisions of Chapter 9(mmmene- APPLIANCES-RESIDENTIAL ]OB DPSCRR''IION
Ingwith Section 70(0)of Division ofthe Buslnessand Professions Cod,and my
licen.),In full force and died. PANELS
Llmnse Claes Liell y���•
Date GHITECl 201-1630AMPS T _ c� i••
UP TO 2DDAbu
ARCHITECTS DECLARATION 1���---//// �..00.
a - OVER 1630 AMPS FT.FLOOR AREA
{Q++O ZO I understand my pkv shall W used as public remNs SQ. f/SQ.FT.
E Licensed Professional SIGNS ELFf_TUCAL
a�I� OWNER-BUILDER DECLARATION SPECIAL CIRCUfT/MLSC
z1.., I hereby affirm that am exempt from the Contractor's License Law for the 99
Q following reasne.(Section 7631.5,Business and Professions Code:An cit r
ey countywhichmquU sapert ttomnstmcl,alter,Impmve,de=lWh,orrepair TEM P.MLr1ER OR POLEINST. ;j
anystmetum pdorto Its a�suance,alsorequire.the applicant for such permit to U1 E 'R
0. file a signed statement that he b licensed pursuant to the provialons of the MOWER DEVICES �,
Ow Contractors License Law(Chapter9(mncingwith SMion70f0)ofDlvl-
each 3 o(the
mmeBuakem and l'ro(e®loco Code)Irthat he 6 m
exem)rt therefroanSWIMMING POOL ELECTRIC
d UAT10N
the Wals for the alleged exemption. Any violation of Section 70M1S by any
65 applicant for a permit subjedsthe applicant to a civil penalty of not more than OUTLETSSWITCIiESFIXTUAES I,a QO
a O five hundred doll..($500), �,�,• ,
i as owner of the roe y employees B NEW RESIDENTIAL ELECTR
�n property,rty,orhe em to seewithova d as STORIES TYPE CONSTRUCTION
c m(Sec.70Kwilldess and Prodim ions Code:
Cormnded LicensreLaw
d for
dile(Sec.does not apply
to Business and f property Coda:TM Contractors hemen Law
$e$ whodoesuch torn owner ofpropertywho
nembuilds orImproves
ovided that such
OCC.GROUP RFS.UNITS
whodoementsa hatintelf dedoough hleowne.If,ho ever,tidMthatsucr
Improvements intended pldio If,however, have
TOTAL: aIYt7V1
Improvement iseold withlnoneyearofcompletlo,theowner-bullderwlll Wve
ttiLtprden of proving that he did not build or Improve for purpose Ideate.). QTY PLUMBING PERMIT FEE pLppDZINE APN
L j L as,mune,of the property,rich a-ludivety contracting with licensed PERMIT ISSUANCE -
mntactom to construct the project(Sec.7654.Business and Profes tom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW A VENT-WATER(EA)
Wild.or Improves thereon, and who centracts for such piokds with a
cgWsdor(s)licanded pursuant to the Contractors Limn.Law. FEE SUMMARY
LII am exem �nder Sec. B k P C for this rea.n BACK FLOW PROTECT.DEVICE
��a��.. qq,��.� DRAINS FLOG ROOF, SANITARY Y N
OUTSIDF FEES
• Owner Data/ (L R AREA,GOND. RECEIPT
_ RKMAN C .A N DECIAR�-ATIONN �a pB(NRES PER TRAP SCI{OOL TAX Y N
❑T here a(llrm that[have a and rate of consent to.If-insure,or a RECEIPT M
certificate o(Workere Compecaatlonln rears,or a unified cepythereof(Sec. GAS PA. INC.40UTLLTS
3800,1.6CJ PARKFEE y N
Policy M GAS EA.SYSTEM-OVER 4(EA) RECEIPT a
Com any BUILDING DIVISION FEES
FCerti6ed copy b herebywith the cityed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
' ❑CertlOed mpyb(Iled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissedlonneed not Wcomplded lfthepermit kforonehundred dollars SEWEILSANITARY-STORM EA.200FT. - Date Receipt#
(sIIrctifyth WATER HEATERW/VENT/MrCTR ENERGY FEE Y N
Ill net emploat y
any person nce In any reaworkcher
so as tobeca became
seelt ubjec Issued, —
1 shag not employ any person In any manner at.to become subject to the WATER SYS.TIM/.TREATING
Workers'Compensation Lawn o(Gllfomla.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT:ILaher ma king this Certificate of Exempllo,you NEW RESIDENTIAL PLMB._SQFr. Date Recel t#
should bemme.ubject to the Workers'Compematlon proviions of the Labor TOTAL:
CC W Code,you must forthwith comply with such provisions orthh permit shall be ,
> deemed revoked. BUILDING FEE
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyaffirm that there is a construction lending agency for the perform. ELECTRIC FEE .j
Z once of the workfor which this permit is issued(Sec.3097,Civ.C.), TOTAL:
L) O Lenders Name PLUMBING FEE
LL H Landers Address QTY. MECHANICAL PERMIT 'FEEMECHANICAL FEE
O W ]certify that l Wveread this application and statethatthe above information
V corms.Iagmetocomptywith all cilyand countyordleancee.nd statelaws PERMIT ISSUANCE FEES PAID'
>_ a relating to building construction,and hereby euthorke representatives of this
~ N city to enter upon the abovo-mentloned property for Inspection purposes. ALTER OR ADD'PD MECH.
? (We)agree to save,Indemnity an d keep harmless the City of Ce pool.. Date 'Receipt#
V a gainrtliabititka,jidgments,mrtsand penseswhlchmayin.nywayacarue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:against sal Inconariase (� grantingofthIspecon
pa�19� AIR HANDLING UNIT(OVER 10,000CIM) CONSTRUCTION TAX
Slgnatureo( ppllant/Cont dor Data EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA2A RDOUS TERIA pa DISCLOSURE
Will the defined
the urebuildingrtio, ocmpantode, car hand 9.haranlow HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the _ Date RCCeI f# s.-.�
I lea lth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 1(0,00)BTM TOTAL: �. .L(/
❑ Yes No '
Will the applicant or cu re building occupant use equipment or devices VENTIbATION FAN(SINGLE RESID) ISapq•C ODATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) ^ ��-`�
Yea nI�No i-t b - y
have read the hazar`Is"o.amatenals requiremanta ueda,Chapter6.95of BORER.C'OMP(OV172100,000 BTU)
the California Health A SafetyCod,Sedims 25505,25533 and 25534, 1 -
understandtWtifthebulldingdoesnetcurrentlyhavestream,that It is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be met City BF est-lirtlnn
prior to Issuance of a Certificate of Occupancy.
Owner or authorimd agent Date ISSUED BY:
TOTAL:
OFFICE COPY