20142 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pm'ect Identification PERMIT NO.
Building Address: 20142
of
ne • ante: TAL DAM
CITY OF CUPERTINOtBUILDING DIVISION
• con a o ;Name: HELI .23 io APPLICATION I PERMIT 7
Architect/Engino Lk No: BUILDING ELECTRICALPLUMBINGMFLHANICAL CATEGORY CONTE InTZ
QTY ELECTRICPERMIT FEa.EX BUILDING PERMIT INFO
Address: I!f LEdr a PERMIT ISSUANCE 495
LICENSED CONTR CTOR'S DECLARATION
T hereby affirm that l am licensed under provisions of Chapter9(c000enc- APPI.IANCESRESMENTIAL ,co JOB DESCRIPTION
ingwlth Section 7000)of Division 3 ofthe Buslnessand ProfesslonsCode,and my PANELS
a3� Q`r�pV/sem
license is In full force and effect /7 �(
License Clam_/_Lic.XS�4D
Date Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 201-1000AMPS
q02 I understand my plans shall be used as public records.. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.Fr.
q��+ COC
lei (a Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CBICUIT/M15C
I hereby affirmthzt I am exempt from the Contractor's Licence law for the
oQ following reason.(Section7031S,Businemand Professions Code:Any city or TEMP METERORPOLE INST.
F� countywhichmqulresaper tiommimMt ter,impmve,demoll•h,ormpalr
a nystmmmpriortoit L ame,alsorequi theappli=tforwchpermltto POWER DEVICES
Ole a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- SWIMM]NGPOOLXLECTFIC VALUATION
SOS the basis fo the alleged exemptions Any violation,
ioM1ebesempt Nerefromand t /` /r DU
Q 5 the bash for the alleged exemption. Any Wolatlon of Section 7031.5 by any OUTLE7SSWITC XTURFS x']� /�5 l�//D
applicant for a permit wbjecuthe applicant to a civil penalty of not nnrethan i [/V
It,-
five hundred dollars(EAO).
r7 1.as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL L TR SQ. STORIES TYPE CONSTRUCTION
Compensation,will do the work and the structure is not Intended or offered for
Osale(Sec.7064,Business and Pmfenlom Code:The Contractor's License law
�$ does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROIIi> RFS.UNI'T'S
EE who doessuchworkelm
hinuorthugh hisownemployess,provided that such
Improvement;are not Intended oroffered forsale.If,however,thebuliding or TOTAL:
Improvementlasold within owyearofcompletiontheowner-builderwill have
t1,,Istrden of proving that he did not Wild or Improve for purpose of sakJ. QTY, PLUM ER FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed P. IT ISSUAN 1`1 00
contractors to mwtmct the project(See 7064,Business and Professions Code: 1 C1
The Contractor's Limns Law don not apply to an owner of property who
Wilds or improves themn, and who contracts for such ptojects with s AL DRAT - '�
�gBtfactor(9)licensed pursuant to the Cort rado's License Law. FEE SUMMARY
LJ I am BACK D E
exempt under Sec B k P C for this reawn OUTSIDEFECS
SANITARY Y_ N_
Owner Date DRAIN RDO OCOM ,
� RECEIPT X
❑I here
WORKMAN COMPENSATION DECLARATION FIXTURES TRAP �L, )asW SCHOOL TAX Y_ N_
by affirm that I have•certificate of consent to self-insure,ce s , RECEIPT X
mniicam ofwmkeri Compensation Insurance or.certified copy thereof pec. GAS, -1 IJCAO PARK FEE Y N
3800,Tab CJ RFGEIxT X
Comp Xny GAS EA.SYSTW-OVER l(EA BUILDING DIVISION FEES
Com Crafied copy is hereby furnished. GRP,ASE/INDUSIRL WASTE 011 PLANCHECK FEE
Certified copy is filed with the city Inspection division. I(J/�6
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID�^17—qo /
COMPENSATION INSURANCE SEWMSANTEARY-STORM EA.I00Ff. Date Recei tM
(Ihi;sectlon need not be completed if the permit b(mane hundred dollars
($100)orlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I rectify that In the performance of the work for which this permit is issued,
I shag not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Revel tN 16 f
Z O NOTICETO APPLICANT:IL after making this Certificate of Exemption,you
should Wmme subject to the Workers'Compensation provisions ofthe Labor TOTAL:
N
Code,you=at forthwith comply with such provisions mthis permit shall he BUILDING - �+u
W j deemed cooked.
CL a CONSTRUCTION LENDING AGENCY SEISMIC FEE !
I hereby affix a that there b a mrutructlon lenciingagenry for the perform- ELECTRIC FEE
7 Z ante ofthe work forwhlchthb permit is Issued&r.3097,CN.CJ TOTAL:
U O Icndere Narre PLUMBING FEE
F Lv.ders Addrens QTY. MECHANICAL PERMIT FEE
Iy MECHANICAL FEE
U betty I agreetvemlywith all
l cltyndcuntyordinances and
Mamatlon z..�t
0 W is correct.lagmmcomplywithelcityand muntyardinanmeand Nate laws PERMIT ISSUANCE �W FEES PAID:'
} IL relating to building mnstmctlon,and hereby authorum repmentalvm of this
F. N city to enter upon the above,mentioned property for Inspection purpose. ALTERORADDTOMECH. %M
? (We)ogre to save,Indemnify an d keep harmless the City of Cupertino Date Recei tN
V against la ,jrdgmenb�,pmrtsand expenses which may In enywayamue AIR HANDLING UNIT(TO I0,000C1M) SUBTOTAL:
mu
against i ity lm �aryceofthe granting o(thla permit AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
ae"Ze
gnalure of Applicant/Contraa ✓ e EXHAIIS'r HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturc building omvp.ot store or handle hazardous HEATINGUMT(TO100,00011TU) Date Recei tN
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
Health and Safety Code Section 25533(a)7 HEATING UNIT(OVER 100,000 STU) TOTAL:
❑Yes �1+�-1.No VFNfILAT10NFAN(SINGLE RESID)
Will the applicant or future building omvpar t use equipment or devim ISSUANCE DATE
which colt hazardous air coma mlwnt•as dell ned by the Bay Area AU
Quality Maiugement District? BOILER-COMP OHP OR 100,0(D BTU) )P_AID,
(
n Yea No
l� `7'have rea11d the hazardous materials requirements under Chapter 6.93 of BOILER-COMP LAVER 100,0011 BTU)
the California Health&Safety Code,Sections 25505,25533 and 75534.I
understand that If the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr. .�
responsibllity to notify the occupant of the requirements which must be met
prior to issuance of a Certificate ofOccupancy.
City of Cuoertl
Owner or authorized agent - Data TOTAL •Ya ISSUED BY:
OFFICE COPY Yl