19738 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PmFert Identification PERMIT NO.
BVldfhg Add.: 19738
93 .��✓i-a/�D Awe
1 ncr assess Phone: ,
/ E.��,l/ CITY OF CUPERTINO-BUILDING DIVISION 70 �t _pO
L
Con ct¢'a Name: L .
/� / . - APPLICATION / PERMIT
v/ �- �'��r'r�• o BUILDING-EIECTMCAI.PLUMBING-MSCI iAMCAL CATEGORY CONTROL#
ArchitM/Englneer. Lic No:
QTY ELECTRIC PERMIT FEE 'BUILDING PERMIT INFO
Addmec PERhIITISSUANCE lczz ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION �J
ThembyaRirm that l am licensed under provisions of Chapmr9(mmmenc APPLIANCES-RESIDENTIAL, JOB D65CRB'IION
ingwlth Sxelon7000)ef DiA.k,n3ofthe BP.i.x nd Pro(ssion.Code,and my
II
cense lath luB(o nd effect. %✓ /�� PANELS .
LI. LIc.N / 7 _ , ^
Date — Contractor
ARCHITECT'S F. A 10 201-IMOAMPS I.
aO Zz I understand my phm shallbe used as public records. OVER 1000 AMPS SQ,FE FLOOR AREA S/SQ,FL
Fi (s Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIItCUIT/MISC
q IhcmbyafBrm that Iamexempt from the Contractor'.License law for the
Q following reason.(Section 7R71S,Business and Professions Code:Any ctry or
ra emntywhichrequircsapev ttoconstruct,altepimpmve,de=lbh,errepair TEMP.METER OR OLE INST.Me`•S anystructurc prlorto its ismance,elsorequiresthe applicentforsuch permitto POWERDEVICES ! .
rN1 UI file a signed statement that he Is licensed pursuant to the provisions of the
3w . Contractors License Law(Chapter 9(mnamocing with Section 7000)of Divi- gWATMING POOL EL RIC VALUATION
BOJ sion3ofthe Business and Professions Cob de)mthat he exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70715 by any
<S appilcantfor a permit subjectsthe applicant to a civil penalty M room rrc than 01177•E7SSNRTCI-IES Eq ^'l bQx CD
live hundred della.WOO. i� •4•
�I,as owner of the property,or my employe.with wages as their rule NEWRESIDENTIALEL TR 1SQ'FT SIDWFS TYPE CONSTRUCTION
compensation,wllldothe work and the structure Is not Intended or offered for f
sale(Sec.7044,Bu.lne..ed Professima Code:TM Contract.e.licewe law
�$ docs not apply to an owner of property who Wilds or Improves theme,and OCC.GROW RES.[INKS
who doeo such work himself or through his awn employees,provided that soch
Improvements are not intended oroffered forsale.If,however,thebuiklingor TOTAL: 2
Improvement b sold within ane yearofcompletloR the owner-bullderwlll have
t n Nen of proving that he did not build or Improve for purpose of sale.). QTY, °. PLUMBI PERMIT FEE FLDou zoNE APN
L as owner of the property,am exclusively cm,—ung wan—need PERMITISSUANCE
contract-et m
to cotron the project(Sec,7044,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who PETER-DRAIN kVENT-WATER(EA)builds or improves thereon,and who contracts f¢such p4ojects with a
cgp((+ctor(s)Emnsed pursuant to the Contractor's Llceme,Law. gp�p(py/pROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
a' Date DRAINS FLOO SANITARY Y N
Owner R ROOF.ARG,GOND. RECEIPT#
�../ WORKMAN COMP.mKifiION DECLARATION to
PB(TIIRESPERTRAP SCHOOL TAX Y N
hereby affirm that I have o mrturanccat.of cmxnt d copy
ora RECEBT#
38M,Ute-f Worker.C-mperuatlonlnsuranre ora certified ropy themoof(Sec. GAS EA,SYSTM-1 INCAOUTLECS
Polly pis C.)�-/�A/(Q/ 03�7� O/j DARK FEE RECFTT#
Cam env (/dJ+wry( "tom irsiiA GAS EA.SYSTEM-OVER4IEA)
,/�/ BUILDING DIVISION FEES
WWCalfirdl mpy b hereby rn�ity GREASE/INDUSCRL WASTE INTERCEPTOR PLANCI'IECKFEE
[✓Mlfied ropy b filed with the city inspection dlvlelm.
CERTIFICATEOFFXEMPTION FROM WORKERS' GREASETRAD PAID
COMPENSATION INSURANCE SEWERSANITARYSFORMEA200PT Date Recel tN
(Chis section need not be completed lithe permit b forom hundred della.
(St Immifc.J WATER HEATER w/vENT/ELECTR ENERGYFEE Y N
I¢rti(y that in the performance of the work forwhkh this permit is blued, —
I%hall not employ any person In any manner so.to become subject to the WATER SYSTEM/TREATING
workers Compensation Law.of California Date PAID
O Z Applicant Date Remi tN
Z O NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT.
Fshould become subject to the Worke.'C-mpematlon provisions of the Labor TOTAL:
L
Code,you at forthwith comply with such providers orthb permit shall be
> deemed revoked. BUILDING E
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE a
I hereby of im,that there is a construction lending agency for the per(erm- E
F
ELECTRIC E
M Z ante of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: EELECTRIC EEE
V O Eandere Name
LL F Tender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I¢rtlfy that(Favercad this eppllcatlon and Yatethat theaboveinformatim
1 6coned.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} W relating to building construction,and hereby authorize representatives of this
(— Z city to enter upon the aboverrentloned property for inspection purpose.. ALTERORADDTOMECH.
_ (We agree to save,Indemnify and keep harmless the City of Cupertino Date Receipt#
%gal 1 Ilitles,pdgmem., sandevpen swhlchmayleatywayacerue AIR HANDLING UNIT 9010,OW CFM) SUBTOTAL:
ago s dCity In Pen h ng of the. rmit PIR HANDLING UNIT(OVER IQODDCFM) CONSTRUCTION TAX
SIg—.turx.&glcxntjCortracmr Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HA7ARDOUS MATCR DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IODODO BTIA Date Recei [p
material as defined by the Cupertino Municipal Code,Chapter 972 and the
Idealth and Safety Cade Se n25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 3
n Yes - o
Will the applleant or Prom building occupant use cqulpment or devices VENTILATION FAN(SINGLE RESID) ISSUAAj ylt)Q1TE
which emit haxardous air contaminants as defined by the Bay Area Alr j�"/'���
Quality Management DLaM BOILER-COMP OTB'OR IWOM BTU) y q(7(}
V.ITJo 1 IJJ�
Zluveria ealtha et matelotsrcons 2555,2553aChapter, 1 of BOILER-COMP(OVER 100,000 BTU) }•k,,� r:
the
erst.omthat IfthebSafety Cdoesode,not currently
have
a toad,that I
b5n., unde.t lb lyat to notify the occupant
pant nolmrmntiyhavea tenant,that It Lamy NEW RESIDENTIAL MECH. SQ.IT. ' a
repo WBlta rocef cern ocmpant of ih qulrcmenle which must be rra't city .IP�y�
pit t once# rtl(I n WLr Lt if
firm
or 2^91rimd agent Date
ISSUED 61'�s`+ FZ`a./ Y�N`.+"�•'C
OFFICE COPY