19789 (2) APPLICANTTO FILL IN'INFORMATION WITHIN RED LINES — USE BALL POINT PEN'ONLY ✓
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Building Project Identification
PERMIT NO.
Building Adds,:
aAvc yon0 - . . 19789
�woslit oss : APIrJCAiiuNbUuN4LIIALIJALh -
CITYOF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT 1
V BUILDINGhl)CTRICALPLUMBINGMLCHAMCAL CATEGORY CONTROL a
Archlted/Engineer. - .Lie.Nee
i..'BUILDING PERMIT INFO,:J ' .
QTY ELECTRIC
Address: PERMITISSUANCE••' p4'I ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am sensed under provision,of Chapter 9(commene APPLIANCESRESIDENTIAL JOB DESCRIPTION
IngwitteSeddon 7000)of Divieion3ofthe Busine,sandProfessionsCode,and my
Ilcense la in fulls it died. V'/ DIq PANELS
License lam LILY Y�� eTf _ , ��'L, (,y (Y/G•�
Date-JS�Contndor O `�.�4v[G. UPTO200AMPq
' ARCHITECTON S DECLARATIMAI$u,ss Aj
xspO lunderstand my pkru shall be used as public recnnls:-' a'�.,,G, - OVER1000AMPS SQ.IT.FLOOR AREA 5/SCI.Fi.
�Zrrd l4,Fj Licensed Prole ede, I - SIGNS ELECTRICAL
Qut - OWNER-BUILDER DECLARATION - I
G Ihemb affirrethatlamexem fromthe Contmetor's Limnselawfearthe SPECIAL CIRCUIT/MISC /
Fo'J S following reason.(Sedien 7031.5,Business and Professions Code:An d or `
W.
FZI"'8 county which requiies a permit to construct,alter,improve,demolish,or repair T'P1NP.METER OR['OLE
� � anystadure prior to It.Issuance,a Iso,mile iies the applicant forsuch permit to
a file a signed statement that he Is licensed pursuant to the pmvlslues of the POWER DEVICES
Owl Contractor's License Law(Chapter 9(commencing with Section 70M)ofDivi-
30 slon3 ofthe Business and Pro(ea,lonsCods)orthat he is exempt themfromand SWBdMINC]VOL VALUATION '
Ile lasts for the alleged exemption. Any violation of Sedlon 7031.5 by any
< appllani for a permit subjects the a pplicant to a civil pewity of room O�'E� '� s Eq ��U �e V`
five hundred dollars($500).
NEW RAD[NTTAI. TR
I a,owner of the ro STORIES TYPE CONSTRUCTION'
anf, p party,or my employees with wages a,Ibelr wk
7< compensation,wllldothe work,and thestrudure Is not intended or offered fort
D
.In(Sec 7044,Bue oc s and Professions Code:The Contractors License Law
$$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUT' - R}S UNTIE
who doessuchwork himself orthrough hlsownemployces,provided that such
Improvements arc not Intended oroffered for sale.Khowever,thebuildingor ' 'TOTAL:
Improvement Lssoldwithinoneyearofcompldion,theowner-builderwillhave ,.
tit,}naden of pmbing that he did not build or improve for purpose o(ale.). Qjy, 'I'i: gi,'PLUMBI NGTERMIT=.�' yt,,r •;,:)�FEG'�;: p- DZONE, APNr,
LJ Las owner of the property,am exclusively contracting with Ilcensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professore Code: '
The Contractor's License Law does not apply to an owner of property who
builds or improves thereon, and who contracts, for such pCojects with a ALTER-DRAIN&VENT-WATER(EA)
c1lt[actor(s)licensed pursuant to the Contractor's Law.
, " s,d •,:4,�FEE!SUMMARYI „
LII am exempt under Sec. B &P C for this maven BACK FLOW PROTECT.DEVICE "
DRAINS-FLOOR,ROOF,AREA,CONTI. SANITARY Y_ N_
_ Owner Date RECEII'f a
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
trfifli hereby affirm that 1 have a certl0ate of consent to eel(-Insure,or RECEITT If
ISIO IA eofWorken',/C�o,m�persatloniwuranaora malfled copythereof(Sec. CAS EA.SYSTEM-I INCAOU`ILETS PARKFEE Y_ N_
3800,Lab CI ' 4"4 !
Pore an LSIc'aaVl� _ RF-CEB'Ia
Com �P�—� CAS EA.SYSTEMLOVER,I(EM -
^fa^Y T`^ �i- BUILDING DIVISION FEES
Certified copy ci hereby fumlehed, CREASE/INDUSTRL WASTE INTFRCFFTOR PLANCHECK PEE -
rtBled copy b flied with the city Iapedlon dlvlston.
e - - GREASE TRAP PAID
' - CERTIFIGTEOF EXEMPTION FROM WORKBRS',
COMPENSATION INSURANCE �' SEWER-SANITARY-SIDRM EA.200F1'. Date Remi t#
(TBlssectlon need fid be completed lithe permit Is forone bund iod dollars
($IM).rless.) - WATER HEATER w/VENT/FI.FLTR ENERGYFEE Y N
I nertilythat In the pedorreanceaf the work forwhich this permit is tanned, ,
I shall not employ any person In any manner w as to become subject tl the WATL72 SYSTPM/TREATING PAID
Workers'Compensation Laws of California. Date .. - - -
Z Applicant NEW RESIDENTIAL PLMB, SQFT. Date Reml t#
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
should become subject to the Workers Compensation provt,loa of the Labor TOTAL:
CC N 'Code you moat forthwith comply with such proWsioa orthh permit hall be - BUILDING .�
W j deemed revoked. '
,0 CONSTRUCTION LENDING AGENCY SEISMIC FEB O
ll. II hereby affirm that there is a coatmdlon lending agency for the perform- SEISMIC
O arm of the work for which this permit is lssucd(Sec.3097,Civ.C.) ' TOTAL:
U Lenders Name PLUMBING FEE
'Ly I- Lender'sAddms, - QTY-:,;GIMECHANICAL PERMIT •t4'ME MECHANICAL FEE
Q W 1cortify that have mad this appliatlonand statetha theabove information
Is cormd.I agree to comply with all city.ed rountyordirtatce.and state lawsPERMTTISSUANCE FEES PAID:
>- CL relating to building coaladlon,and hereby authodu representatives of this Z city to enter upon the above,mentioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Remi I#
V —. (We)agree to save,Indemnify an d keep harmless the City of Cupertino " -
galnstllabilhies,judgmente,coats a fid expenses which may In any way accrue ' AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
gas ,old C1 Inco sisquence of the grant Ing of this permit.
_ _ S_ yAIR HANDLING UT(OVER 10,0D0 CEM) CONSTRUCTION TAX _
� MCONSTRUCTION TAX PAID:
Signa re of AppllcAZAR nOUS Date EXHAUST HOOD(W/DUCT)
HAZARDOUSM DISCLOSUR or ha ed
Will thealas apnexibothefuture building nccipad Code,Chapter
9.hazardous HEATING UNIT(TO 100,000 BTU) _Date ReceI t#
material and
defined l4,the Cupertino Munldpal Code,Chapter 9.1 2,and the• —
PlcalthandSafetyCodeL No 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: t
❑,Yes No i ,
WIIl the applicant or afore building ocapant use equipment or devices' VEMDLATION FAN(SINGLE RE.SID) .IS$UA DATE
which emit harardous air contaminants as dell tied by the Bay Arca Air "
Quality Management Dlstrlct7 BOILER-COMPO}E'OR If10,0008TU) MAR
[?have Yes n1c us II II 11T\ 1
radteclth& fMyC(d,S requiremenlsunde ,Cd25534. 15 o( ' - BOILER-COMP(OVER 100,000 BTU) .,
the
understand
t Health building Safety Code,Sedioa 255B5,ve a ternd,that
hat it
usponsi tidy to notifytheoccupant
not a currently haves tenanq thatb isot NEW RESIDENTIAL MECFi. - SQ.IT CI /nf rq!1pLf�An
responsibility Issuance
ce of notifytheof Ocllhe requirements which must be met
prior to issuance ofa Certificate olOauparty. -
ANA
- ��a �_]�~T .��
Owner_or authorized agent.' Data s��
-' ISSUEDBY:
G - -t -
TOTAL:
OFFICE COPY .