20718 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proea Identification - PERMITNO.
Building Addre a:
44A2saN Emla L- 2071
ane:
J•awe-s 1 7-r.U78 CITY OF CUPERTINO-BUILDING DIVISION
Contr`cmr'sN.mn: 1a.No: APPLICATION / PERMIT ^�.
JQ Sd2 S �^ BUR.DINGELBCTRICALpLUMBING-MECHANICAL CATEGORY CONTROL/,' 13
A ect/Engineer. LIB Ntx b
S- BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address: PERhBTISSUANCE 16 �l 9
LICENSED COensed under
pr DECLARATION 1�)
I hereby i..700hatlam licensed mond ro Cha sCode,anen APPLIANCESAESIDENTIAL
Y p pl JOB DESCABa770N
Ingwllh In
o(thegudnemand ProfemloneCode,and my
Larios le in rre and effect PANELS
Liven tam Lk.NSOZ S� l �W
Dale Cui
ontaao
ARCHITECTS DECLARATION 201-IODOAMPS
M 2 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k Licensed Prufemlanal SIGNSELECTRIGL ��
rid OWNER-BUILDER DECLARATION a?
Ian] SPECIAL CIRCUIT/M1SC
7 I"'YI ,hereby ...firm tMtIamexempt from the d I'miclorb.License Code:Lw(orthe
rNyoo qqq county hichre .heel pormil to onanemand Proprove, Code:Any atyar a� �� `_
anystm which regrtoia eranceal mmqui theapiluntfrr..b prrepair Ta'1P.MEl"[IROAI'OLE U k7
q� anyatrocNrestatementehathe Is alcensed rcrsuant to
forsuN peof t e POWER DEVICES
Ok a signed statement that k k licensed pursuant to the provisions of the
W6 Contractor's License Law(Cha er9(commentln with Section 7000 of Dlvl- VALUATION
H�OQ tlon3ofthe Business and ProfembnaCode)orthaghe is exempttherefromand SWIMMING POOL BLE h
6 5 the Loeb for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCFFES //// / V
O applicant for a permit subjects the applicant to a civil penalty of not more than 70 't
qV
five hundred dollars(5500). TYPE CONSTRUCTION
R NEW RESIDENTIAL SQ.FT. SCONIES-
F1e saower of the properly,or my employees n with wages r [here sok
ttact mmpensaHon,will dothe work and the strudure L+na intended or offered for
5 ❑ ass not apply to alweaMf property who
or improves
mptheme,
law
doesn.s ap rkhan w U rth= hhis o nem aym pro idedthat eh OCC.GROUP RES.UNITS
0.0. whodoementsa or nMmxnded ormgh Nsowne.If,ho ee,prwWed[hatmch
Improvementsarenot Intended earotco formic.If,however, deer ilin oar TOTAL:
ImprovemeMbwld withinorleyearalcomplelbn,theowner-0ullderwlll have
1 rden of proving that he did not build or improve for purpose of role.). QTY PIJUMBING PERMIT FLW NH AIN
Lj I,as owner of the property,am exclusively contracting with licensed IT ANCB
contractors to comec troct the project(S7044,Business and Professbru Code:
The Contractor's Llcerue Law does not apply to an owner of property who _ RAIN AVENT-WATBR(EA)
builds or Improves thaece,and who contracts for such Inp*c a with a FEE SUMMARY
OUTSIDE
a'gR{(aam(1)Ikensed pursuant to the CcntraRor'e Llconse Law. IX WPROTECT.DEVICE
1_J I am exempt under Sec. B k P C for Nle n
N FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date BBC=Y
WORKMAN COMPENSATION OECLA ATION FL WS
❑I hereby affirm that I have a certlRote of can et to self-In m,ora FD(1V PER TRAP SCHOOLTAX i061-1
N_
EB Y
/
.Ali late o(Worken'Comperuationlesunnamac I(kd copy the ((Sec. GAS EA SYSTEM-1 C40UTLETS PAAKFTE Y N
mou'Lab CJ
potiry Y RECEI'I M
Com any CAS FA.SYSTEM-0 R4 BUILDING OI VISION FE ES
CertiOed copy k hereby furnished. GREASE/IND STRL SEE FPTOR P CHECK FEE
CedNed mpyklBed with the city
lTpNet
.
CERTIFIGTE OF IXFt..1PTIKERS' GREASETRAPAID lS-r/l
COMPENSATION SEWER SANTTAB -SIU EA ZOOFT Date
(Thiasectkn need not be completed Ble hundred dollars
(6100)orlesa) WATER HEATERVENT ECTR ENERGY FEE Y N
I mrtifythat in the performance of the work rorwhich this pemdt is issued,
I shall not employ any person In any manner in as to become subject to the
WorkersComNnsatlon laws of Callfomla.Dale WATER S1Sf8A7/TREATING PAID 2k3,0
O Z Applicant NEW RES DEN RAL PLMB._QFf Date Revel t#
Z O NOTICE TO APPLICANT:If,aftermaking this Certificate of Exemption,you
Hshouldbemmesubodtothe Workers'Comperuatiuh.p(uvbiona of the Labor TOTAL:
jr N Code,you=at forthwith comply with such provisions orthls permit shall be I IN 'E
IL j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffirmthat there is a comtmdton lending agency forthe perform ELECTRICFEE
D Z arae(the work(or which this permit is kased(Sec.3097,Civ.C.) - TOTAL: /
C) O lerdae.Name PLUMBING FEE N/
IL H Underepddecas - QTY. MECHANICA ERMIT FEE MECHANICAL FEE
O W
kcoI mmilythat I have readthisappliatlonand statethat the above inmoustian
1 rrect.Iagreetocomplywlthal amty
tyand unordlnanmsand statetaws PERMITISSUANCE FEES PAID'.
W relatingtobuliding corotroctlon,and hereby authorize representatives ofthk
Fdtyto enterupon the abovcmentiomd property for inspection purposes. ALTERORADD MECH.
Z (We)agree to save,Indemnify an d keep harndem the Cityof Cupertino Date Recei t#
V agalrstliabi@ks,judgments,mstse,de.t witichmayinanywayaccue AIR HANDL, UNET(TO 10,000cphi)' SUBTOTAL:
ago Imt sald City in conaaryena of fin ng of this pct It.
.�� 7 AIRHA NGIINTT(OVER70,000CFM) CONSTRUCTION TAX
sl reof AppBant/Contr aor to Ex THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building orcupant.toreor handle harardom FATING UNITHO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter 9.I$and the
Healthand Cade Section 75532(.)4 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Wal the applicant or Tdum building occupant use equipment or devices VENTILATION FAN(SINGLE RES(D) ISSUANCE DATE
which emit harardousalr cortaminantsas defined by the Bay Area Air
QaalityM BOILER-COMP pFB'DR 100,IXp BTU)
j Ye. est District?
I have read the hares sus materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 75534. I _
undersla nd that if the bulldieg does not currently have a tenant.that It is my NEW RESIDENTIAL MF.CH. SQ.FT.
responsibility to rally the occupant of the requirements which must be met '
rlor to lssuanre ofa Certiflate of Occvpan
ner car authodred agent Date ISSUED BY:
TOTAL:
OFFICE COPY