20081 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Build Ing Project Identification _ PERMIT NO.
Building Add mss: /1 O O n
ZD me / 4MP&)i l G �8
wnere ams: - one: APPLICATION SUBM I FAL
CITY OF CUPERTINO-BUILDING DIVISION
�la� Lie.No: APPLICATION / PERMIT Com` e Ci V'
lot;
�e BUILDING-ELF MCAL-PLUMBING-MECI AMCAL CATEGORY CONTROL N
ArcMtea/Engineer: Lie.No
" ' '- 6. ,•'[,BUILDING PERMITiNFO "`I^
' c -([ /� 'Qn' '.ELECTRIC PERMIT ' ,FCC
Address: �Sa 'S l4 2lSC DK.., PERMITISSUANCE ._ '.
LICENSED CONTRACTOR'S DECLARATION E
[hereby efflrmthatlamllerneed underprovlslone of Cha ptcr9(ca.c APPLIANCES RESIDENTIAL JOB RIPION
InenseiSection force andfdied. ofthe Buslrteeeand Profnalone Code,and my ('/ �
license le in ection force and died. PANELS LI[-, �(((//`A�
License Claes LION •9t L'!1
Date Contractor UP TO 2DO AMES
ARCHITECTS DECLARATION 201-IODOAMPS
q�q�++caO Zp l understand my plans shall Ina used an Public records. - OVERIOWAMPS -r-- SQ.IT.FLOOR AREA S/✓Q.FT. •
Licensed Professional - SIGNSELECTRICAL e n n 1"� 1-• _ , .
, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC ( -
Z., ffi
I hereby that l am exempt from the Contractor's License Law for the
O •1 '?( i� il� -
following reason.(Section 70315,Business and Professions Code:Any city or
F I:. rouTEMP.METER OR POLE INST
pppp ntywhkhrequiresaper ttommtmo,alter, pmvemo
,delish,ormpalr 'Q I4,/tea
$EO anyetmcturcprior toits bsuance,aLso requlreetheappllcant(or such perrNt to
Is s, POWER DEVICES 41v���ag7
�'•4,'a file a signed statement that he licensed pursuant to the provisionof the .N
3w Contractor's License Ls-IChapwrI(comem.eing with Section 7001.1 Dlvl- (L
O slnn3.fthe Busineasand Profeadma Code).rthat he h exempt therefroarand SWIMMING POOL ELECTRIC' VALUATION
Q the basis for the alleged exemption. Any violation of Section 7m L5 by any OUTLETS-SWITCHES-FIXTURES
applicant for a permit subjects the applicant to a civil penalty of not more than
veh
.. li , reddollars
"4 as owner of the heproperty,or my employee with wages as their sale SQ.Er: STORIES TYPECONSTRUCTION sole NEW RESIDAL ELECTR
compensation,wlEdothe work endthe structure O not Intended or offered for
C� Cl In(Sec.7074,Business and Professions Code:The Contractors License Law
$ does not apply to an owner of property who Wilde or improves thereon,and
who does such work himself orthrough his own employees,provided that such OCC.GROUP RIS.UNITS
Improvementsare not latendedoroftered forsals.](however,thebullding or TOTAq Q.SO
Improvement is sold within oneyearofcompletion,the owner-W liderwill have 77—
06,den of proving that he did not build or improve for purpose of sale.). Qsed 'j'y, ai,lt+•.`I LJMBI G- E MFIi I'''F'' + .'a.��FEE'•t FLOOD/DNE, APN
06
],as owner of the property,am exclusively contracting with licen
contractor to construct the project(Sec.7044,Business and Professions,Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DW& _ .�
Wilds or Improve.thereon, and who contracts for such p�ojacte with a 'i'6"i„1 +,FEE$DMMARY
cgB$actor(s)Bernard pursuant to the Contranols Llmove Law. !_ BA TEC DEVICE • -
IJ I am under c. B k P C (err thio rcawn
Owner Date D F R ,A GOND., SANITARY Y_ N_
RECEOrr p
WORICi AN COMPENSATION DECLARATION -
❑I hereby affirm that I have a certificate of comene.to self-Insure,o _PER SCHOOLTAX YRECEIPT N
N
cedifinteof Worken'Compemation kd
Luumnmoramn(fropythereof(Se AS Et UILELB ppRi(p� y N
.. 3800,Lab C.) - -
PolicyN — RECEIPTM -.
Com any _ C E N 1 BUILDING DIVISION FEES
Ca
copy is hereby Iumished. GREI LW SIEIMFRCEMOR PLANGI-IEGIC Fee
❑Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID + .
COMPENSATION INSURANCE SEWERSA ARY-STORM EA.200FI. Date RCOCI IN
(Thissection need not be completed lithe permit b foron,hundred dollars
(sletBarless3 WATER IIGTQt W/VENT/E-CCTR ENERGY FEE Y_ N
er "
I rtl/y that In the performance of thework forwhlch thio permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TRGTINC
Workers'Compensation Lswa of California. Date PAID
licant
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,You NEW RESIDENTIAL PLMB.' SQ.IT. Date Recei tis
H should became subject to the Worker'Compewt ion provisions,.,the
Labor - TOTAL:
N
Code,you must forthwith comply with such provisions or this perrN[shall be,
LU > deemed tavoked. _BUILDING FEE
a C
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is construction lending agency for the perform /�/0' ELECTRIC FEE
D Z once of the work for which this permit b Issued(Sec.3097,Civ,C.) TOTAL:
00 Lender'.Name 7 PLUMBING FEE QQ
H Lender'.Address QTY. MECFIANICAL.PERMIT + +. FEE,'
LL - - MECHANICAL FEE
O W Imdlfyth agree
comply
hba all city and county dformation
1 bmrrect.(agree to complywith an city and county oNinancent.twate lawn PERMIT ISSUANCE FEES PAID:
} relating to building cowtructlon,and hereby authorize representativee of thio _
(— 2 city to enter upon the above¢nsatloned property for inspection purposes. ALTE70RAODTOMECH. Date 'Betel HIu -
_ (We)agree to save,indemnify an d keep harmless the City of Coped inc,
against liabilities,judgments,acensand e.psa.which may In any way... AIR HANDLING UNIT ITO IQOOo CFM[ SUBTOTAL:
against said City In consequence of the great lag of this permit. -
_ AIR HANDLI NG UNIT(OVER 10,060 CrM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllm nt orfuture building occupant store or ha nd In hazardous HEATING UNIT(TO 100,000 BTU)' Date Reeel IN
materlat as defined by the Cupertino Munlctpal Code Chapter 9.12,and the a.�
Iicalth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' J
F1Yes M No - -
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE MID) - ISSUANCE DATE
which emit harardous air contaminants an defined by the Bay Area Air a
Quality Management Disko? BOILER-COMP DIIPOR 100,DM BTU) Rie9po
4Yca (�No
havemsdthehaza7ou�materlalsrequlrementsunderChapter6.95.f' BOILER-COMP(OVE2100,000RN) p�jn' �yyu
the Callfornb Health&Szfet Code,Sectioro75505,25533 and 75534. 1 APR
understand that it the building does not currently have a tenant,that it is my NEWRESIDENIIAL MECH. SQ.FT.
nsponsl to not If y then pa fthe quircments which most be met,
prior u e of a Coil to ' o cy. - . r f GunQr}L4�Bn
Ow......otko axii.gent Data
TOTAL:. ISSUED Ll7.a
-''
OFFICE COPY