20044 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Su Main Proet Md ulV. [ PIlA9TNO.
B.ua12ng-ndmesa6 e � o v. 20044
we. r'.1 P CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: IJc.Na. APPLICATION / PERMIT lJ LJ —LJ9
4N BUILDbNGFlFS.-SRICA MP BING-MECHANICAL CATEGORY CONTROL,I
G— Lk"'« QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address o K TSSo F PER1,4TISSUANCE ❑
LICENSED CONTRACEOR'S DECLARATION 1:1 1:19
I hereby afflim that l am licensed under prwwons of Chapter 9(mmmene APPLIANCESRE4DENMI, pB DESCRIPTION
Ingwith isI tbn]00feand vfnct3 ftheBuJrmand PmleealonaCadesand my I e1C7r., F }'SUP �/
Ilmnne isle/uB force and effect. PANELS •—I"'7Q�-J hal t '^+'—�•,
Llreruc Claeq LILY
Dated./ _ Comncwr anica1 PLUKEt
ARCHITECTS DECLARATION - 201-1000AMPS
Q Z I understand my plans shall be,used u public records. OVER 1000 AMPS SQ.FE.FLOOR AREA $/SO.FT.
u�y�O Llorued Pn{embnal SIGNS ELECTRICAL
i�j
< OWNER-BUILDER DECLARATION SPECIAL CIRCNT/MLSC -
p 5 1herebyaffirmthatIamnemptfmmthe Comr ors License]awforthe
>Q 6 following reasom.(Section 70313,BuJnuand Pmf®lens Code MyyorcitTEMP.METIR OR POLE INSF.
Fy countywhkh requhnapermbtommtmgalbr,lmprwe,demoWh,orrepalr
4 any.mIchre pdmtoib Lwance,aleortqulmtheapplfantfomdt permNto POWER DEVICES
KqO (Ila s Jgned statement"'an M b licensed pursuant to the provisions of the
ContnRor'eLien.lazwf(7hapter9(mmmencing with Section A)(())of Div
SWIfAMNG POOL ELECTRIC
0.71 xion3 ofthe Bu Jnesa and Pmfewbm Code)orthrt he Is exempt therefmmarvi — VALUATION
fS<5 the lets for the alleged exemption. Any violation of Section MIS by any OUTI.ETSSWITCIESFiJ(TURES
Mai appBcantfora pemOt ubjecta the applicant too civil penalty Nrwt more elan
E By hundred sun($S00). NEW R®FNDALELECTRF7
- SQ . STORIES TYPE CONSTRUCTION
C 7< 1, lu
as cone of the Property,or my employ.with wages u their win
psnsnbn, W
wdothework,andthestmdumbrotIrdeMd or offeredfor
❑ sale(Sec 70M,RuJmns ami Pdesbna Code:The Contractor's Plceme law
�sg doe mtappiytoae awrcc&pmpertywhob.1[6o,imp.the.,.d OCC.GROUP RES.UNITS
who doessuch work himselforthnough hiaown empleyoet Provided that urh
Improvements arc net Intended oroffered fosale.If,hovever,the building or TOTAL;
Improvement bsoid wfthn omyearofcrmtpI&ion,theovmr- Ilderw111 have
t rden of proving Nhe did nor build or Improve for purpose ofsala.). QTY. PLUMBING PERMIT FEE
UI, at as owner of the proputy,am exclustwly emir—mg wkh FLOOD ZONE AINIbensed R L%UANCE
contract.to consumer the project(Sec 7W{,Business Business and Pmfmbru Cade: t
The Coiunc on's Lima Law don not apply to an owner of property who ALTER-DRAIN VENT-WATER(FA)
builds or Improve thneon, and who mMraRa for such p(ojeb with a.
ogwcto(s)Iloensed purawnt to the Contractor's License I,aw. FEE SUMMARY
U I am exempt under Sec B &P C for thio reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,GOND. SANFTARY Y N
Owner Date RECm N
WORKMAN COMPENSATION DECLARATION
®T hereby affirm that I have a certirncoself-Inure,
te of connect to or FIXTIJR6 PER TRAP SCITOOL TAX Y N
certificate of Workers'Compensation Insurance ora certlfbd copy thereof t$sc. RFLER'T a
3800,Lab G) GAS FA.SYSE07.1 1NG4 OLFD.ETS PARK FEE Y_ N
E11711-
Co Y__O(]1�Q IT 779 RINGDIV
W 1 CAS PA.SYSTFMOVEA{(EA)
Co�pa v— dllS all R--S—(;O. BUILDING DI VISION FEES
DC ccertNed copy d hertbyth tWhea. GREASE/INDUSIRL WASDi INTFRCEI'NR PLANCHECK FEE
kC'Jq certmea copy b filed hereby( the city Irmpetlbn alvWm.
CERTIF[CATE OF EXEMPTION FROM WORKERS' CAFASE TRAP' PAID
COMPF SATION INSURANCE Sh'WFR-SANRARY-STORM EA.3TQr1' Date RCCCI [N
(Phbeectbn need not be completed if the permit b lar cam hundred dollar
mw)oris.) WATER riEATFR w/vENr/p�.Ec-TR ENERGY FEE Y_ N
Itertffythat Ntheperformanceoftheworkforwmathispem bWiled, —
I shag not emrpioy any pew le any manner so u to become ub)ect to We WAT[R SYSIFAL/'TIBFATING
Work,an'Compensation Laws of Callfomb.Dale PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Rece1 tM
Z p NOTICE TO APPLICANT:lf,after inking this Certificate of Exemppttlen,you N TOTAL:should becomesubyrt to the Workers'Compensation provisions oftbe Labor
Code,you Cwt fothwhh comply with such provisions or this permit shell be �Jo
BUILDING FEE
LU ] deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC PEE
1 Hereby worm,that Ilene isi•construction lending D97,C ler the perform, ELECTRIC FEE
7 Z anceoothe work for whkhthb pemNtbb,tred Qec.3097,CW.CJ TOTALRk�
02 1,ander.Addr PLUMBING FEELL o
0 I,ander'.Aaa�a QTY. MECHANICAL PERMIT FEE
O W Lo�t�y h agree
.ply apaBatlona dente hrtrhea wand ormeao MECHANICAL FEB
bcorrect.baileeg conplywhhaB harab munealiesruneesanE,es state of two PERMRISSTIANCE FEES PAID:
} N rtytoe.ter.p.ng ronslmNou,ard hereby sty o reepternhtive of thin
F Z
citytoto theabove.rrcmbned property for Wpe Cit purpose. ALTER OR ADD TO MFi77. Date Recef tq
(We)agree to ave,bdemnity and keep es whes the City y Cupartbm
U ago Wt Wbruln,�edgmenis,rmband expenses which mayb any way accrue AIR biANDLING UNIT(IO 10,000 CFM) SUBTOTAL:
ago Wt said City In consequence of tic gra atbg of this permit.
'ZS AIR b-uNlwnc UNIT(OVER 10,000 cEn() CONSTRUCTION TAX
litre.m of Apphomu/Con or Date EICHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applkant or future bu0ding occupant store or handle ha,cadous HEATING UNIT(10 1M,"BTU) Date Recel tit
materlal as defimd by the Cupsim.Municipal Cade,Chapter 9.1Z and the
I leallh and SafetyCode Section 25531(a)1 HEATING UNITE(OVER IOQ0(10 RTU) TOTAL:
RYe N No
Bl the applicant orfuture building occupant uw equipment or device VENTILATION FAN 6INGLE RESID) RAGI1,11RlfC
which emit heamPOW DATE air conta
h ants as defined by the Say Area Air i�
Thy Mansgsm xm District? BOILER-COMP OI-0'OR 100,000 BTU)
IQ Yesrb JUN b 6 1950
I have read the h.m.materials requirements under Chapter&95 of BOMMZCOMP(OVER 1 W'"lam
the Calif.].Health&Safety Code,Sections 25SO5,8573 and 75536. I
undcnUnd that if the building does not currently have a tsrunt that It b my NEW RESIDENTIAL MECH. SQn. aa.s�� /a ,y,
roporuibility to notify the occupant mi
of the requiments W which rtuat be met �BDP.1ti RO -
p' to bila are of a Certibc to fO<rupaoy.
, +�.Z
Owner m authoci atnt DateTOTAL:
\ OFFICE COPY