19895 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
G✓ /J, 4/ 19895
7f 1�rcds,
.ere time. Phone: APPL1CAr5KT09.qrrrATA
CITY OF CUPERTINO-BUILDING DIVISION
Contr or'.Name: L+c.Nn/ APPLICATION /PERMIT
5 3536 BU LDINGELECTRICALPLUMBING-MECFIAMCAL CATEGORY CONTROL N
-Architect/Engine f Lic.No:
QTY ELECTRIC PERMIT FE,E,x� BUILDING PERMIT INFO
Address: PERMITISSUANCE 1/�W ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm thatlam Bcenud underprovlalons of Chaper9(comme APPWANCESRESIDENML JOB DFSCRIHON
Ingwlth5 ion7000)of MAsimn3oftheBuMnessand Pmfaims Code,and my
license lam mu force ti iee // PANELS
License Clan G,kV lD LLCMll ;57�9 35340 {
Dale ��zN ' _Cantnctor /L-IICa�
ARCHITECTS DEC"R TION pl-1� PS
04 Z 1 understand my pian shag be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
x�iOSIGNSELECTRICAL
�j Licensed Professional
Q Q Oyu OWNER-BUILDER DECLARATION
p J IherebfB
yarm that am exempt from the Contractor's License Law for the SPECIAL CR2CUli/MIST
ZOZ � following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
countywhich requires a permittoconstmcl,alter,Improve,demolish,orrepair
1m a any stroctum prlorto its issuance,also requlresthe applicant forsuch permit° POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
O a Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIP(MING POOL ELECTRIC
30� Mon 3ofthe Buslnestand ProfessionsCode)orthat hela cunt therefromand - VALUATION
< the basis for the alleged exemption. Any violation of Section 70115 by any OUTLETSSW1MHESFTXTLJRES
Q applicant fora permit subjectathe applicant toa civil penalty dna morethan
cg C"i five hundred dollars%5M. NEW RESIDENTIAL ELECTR
?�n
F1 1,as owner of the property,or my employs with wages as their sole �'�' SI'ORIGae TYPE CONSTRUCTION
76 compensation,waldoehe work t
and thestruure is not intended or offered for
p sale(See 7064,Business and Proressioru Code:The Contractors License law sn
$ does not apply to an owner d property who Wilda or improves thereon,and
a$^ whodoessuchworkhimselforthrough hisownemployes,provided thalsuch �^ OCC.GROU[' RFS.UNITS
Improvements are not intended muttered for sale.ILhwvevegthebulldlegw TOTAL: rt�
improvement lased withinoneyearofeompletlon,the owner-bullderwlll have
t119�*,rden of proving that he did not bund or improve for purpose ofealeJ. QTY. PLUMBING P MIT FEE FLOOD ZONE APN
IJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractorsto..trvct the project(Sec.7014 Business and Professions Code:
The Contractors License law don not apply to an owner of property who ALTER-DRAIN&VENT r7:A)
Wilds or Improve theeeon, and who contracts for.& ptojects with a
c9alr ctor(s)licensed pursuant to the Contractor'•License Law. FEE SUMMARY
LJ I am exempt under Sec B&P C for this rcawn BACK FLOW PROTECT.D E
OUTSIDE IFFES
DRAINSROOF,A . CO SANITARY Y_ N_
. Owner Date RECEIPT N
WORK MAN COMPINSATION DECLARATION MnIt SCHOOLTA% Y_ N_
❑I hereby af(Inn that I have a cemlfinte of consent to self-insure,or a RECEIPT N
certificate of W.rke.'C.mpetI.insurance ora metifkd copythereof(Sce. GAS EA.Sy OUTL PARK FEE Y_ N_
IN00c# CJ RECEIPTN
Co any _r GAS EA.SY51T2aR4(EA) BUILDING DIVISION FEES
ffComified copy is hereby furnished. GREASE/INDUSILA .
L WINT TOR PLANCI'IECKFEE
T4Cemified copy 6 filed with the city inspection division.
�"l CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFT Date Remi t#
(fhlssection need not ed completed If the permit is forms hundred dollars
(S100)orless.) WATER HEATER W/VENT/ELGCTR ENERGY FEE Y_ N_
I mmify,that la m
the perfoumceof the werk for which this pemdt is astound,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers'Compensation Laws of California. Date
O Z Applicant NEWRES[DENLALPLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:1L after ma king this Ccmiflcam of Exemption,you
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
H res Code,you at forthwith comply withsuch provlalons orthis permitahail be BUILDING
� > deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE Q�
7 Z aura of the work for which this permit b Issued(Sec.3097,Civ.C.) PLUMBING PEE
02 Lender's Name
LL I— I<naer:��NNddarcaa QTY. MECHANICAL PERMIT FEE MECHANICALFEE
U Iwggfihatl have read thbappBcationand Matethattheabove lnrormatlan
O W lacomor.l agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} M 'Wing"tmbuilding constructlon,and herebyauhomu representatives ofehis
Zcity to enter upon the aWve-medloned property for bupetion purposes. JALTERORADDTOMTDCH. Date Re,ceipt#
(We)agree to save,indemdfy an d lamp harmless the City of Cu pemino U AIR HANDLING UNIT(TO 10,000 CFM)against liabilities,judgments,costs and expenses which may In any way accrue SUBTOTAL:
ago Wt said City In consequence of the granting d this pemrdt.
AIR]iANDIdNG IJh7T(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAusr HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutumbulldingompant store or handle hazardous HEATING UNIT(TO IDg000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 1,and the
Health and Safety Code Section 2S531(a)7 HEATING UNIT(OVER 100,DOO BTM TOTAL:
M Will
r]No VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
WIII me applicant or future building occupant use equipment w devices
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Marugcment District? BOILER-COMP OHPOR 100,000 BTU)
Ye No
have read the h.Qu materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the Califemla Health&Safety Code,Sections]550.5,25533 and 25536. I
undersea lid that if the build Ing does not co mently have a tenant,that it is my NEWBESIDENHALMECH. SQ.FT.
responsibility to notify the occupant of the mqulrcmsnts which at be met
prior to issuance of a Certificate of Occupancy. 1.
Owncr or authorised agent Date
TOTAL: ISSUED BY:
OFFICE COPY