24189 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO
418 9
Building Address: L O
ne
a ams: one. APPUCA HON SUBMITTALA
2;', Iia^ yens 25 - ' a-13 CITY OF CUPERTINO-BUILDING DIVISION �^
ContractoraName: — LIc.N. APPLICATION I PERMIT '
'�' d 60a-S�!— Z.7I ` I 6 BUILDING-FLECTRICAGML BINGMECHAMCAL
rchitect/Esgineem Lk.Nec CATEGORY CONTROL p
5 1 �j l✓• S A/!'rm C/tuZ BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Address: Lt 1, f_,,4 yaS r S DE PERMTISSUANCE �0� Y� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm that am licensed under provisions of Chapter 9(comdmene APPLIANCESRESIDENrTIAL JOB DESCRIPTION
Ingwith ScMon70M)otDiv(alon3ofthe Buslneaand Pref nglonsCode,and my
license la In full fo and dme. ...1 —// y PANELS
LlrnnseC o Lk.M Z
Dat'7 1 Contractor
ARCHITECTS DECLARATION 701-1000 APS
X 0_' I understand my plans shall be used as public records OVMERI000AMPS W S/SQ.FT.
o u Licensed Professional - SIGNS ELECTRICAL
6
�< OWNER-BUILDER DECLARATION o R
SPFCIALCIACUIT/MISC E
Thereby a(Ormthatlam execop[(romihe Contractor's License Law forthe /
following reason.(Section 7MIS,Business and Profealmu,Code:M n or
p,
O�I"u1 n whichr Tress ermitloconstruct,alterim y Fa TEMP. OR POLE INSI. D E
�y cruty equ p provntforsbh,erre o
anyatrocture pater entshvancq asw requimtheappRant forsuch permit to
O 0.V file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES
Contractor's Lkense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRICslon3of the Businessand Professions Code)or that he is exempt therefrom and LUATION
the basisfor the alleged exemption. My violation of Stolon 70315 by any
<0 5 OVIIETSSN7TCHFSFIXTIIRES /q
apphomt fora permit subjetcathe applicant to a civil penalty of not more than 1E—00
61
five hundred dollars(S5M.
I,as owner,of the NEW RESIDENTIALELECTR SQFI, STORlf5
7acompensation,wllldothe work andthee structure Is "traded or (ered for o TYPE CONSTRUCTION
D sale(Sr.7C4 Business and Prefealons Code:TheContractor,License Taw
( 5� does not apply to an owner of property who Wilds or Improves thereon,andOCC.GROUT' RES UNITS
who doessuchwork himself r through Msown employees,provided that such pp
Improvementsare not intended oroffered formic.IL however thebulldingor TOTAL: .Q p
Improvement hwld withinoneyearofcompletion,theowner-budderwllHuve
t en ofpmving that he did not build orimprove for purposeo(sale.). QTY. PLUMBING PERMIT FEEplppD7DIYE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractorsto construct the project(Sec.7044,Businem and ProfessionsCode:
The Commencers License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves, thereon, and who contracts for such pjojecta with a
c�DtT+cir(s)Bcens=d pursuant to Me Coneractr'a License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
LJ 1 am exempt under Sec. B&P C for this mission
Owner Dace DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT M
=eurmbY affirm that I have a certificate of consent to self,hurom or FD(TURFS.PER TRAP SCITOOL TAX Y_ N_
mdifleste of Workers'Cempensation lmuranmora certified mpy thereof(Sec. RECEIPT a
oq iSyam � B— GS EA.SYSTEM-t INC.d OUTLETS PARKFEE Y_ N
mfC4� / GAS EA.SYSTEM-OVER 4(EA) CIPT#
rtCoNed copy hereby furnished. BUILDINGRECEIPT
DIVISION
FEES
E]Certlfled copy is filed with the city Inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
6�
CERTIFICATEMPE IXEMPN NS FROM WORKERS' GREASE TRAP PAID
COMPENSATION ATIONIN INSURANCE
(Tculessonneed nelhecamplMed Rehe permit uforone hundred dollars SEWER-SANITARY-STORM FA.700FT. Dale RCYCI t#
(4100)r Ica.)
Icertify that In the perforranroftha work forwMch this permit is boded, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
1'ha 11 nr employ any person in any manner w as to become subject to the —
Workers'Compensation Laws m Caflf.mta.Date WATER SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recei tic
Fshould become subject to the Worke%'Compensation pnwulom of the Labor TOTAL:
N Code,you must forthwith comply withsuch provisions orthis permit shallbe
LU > dercrad revoked. _ BUILDING FEEJAID
a p CONSTRUCTION LENDING AGENCY -SEISMIC FEEZI hereby affirm that there ba mnstroctimn lending agency forthe perform TOTAL ELECTRIC FEEance of the work for which this permit b signed(Sec 3097,Ch.C3 O Tenders Name PLUMBING FELL F Lender,Address QTY. MECHANICAL PERMIT FEEOW Irnrtifythatl have read thbapplirtlonand tate that the above information MECHANICALbmrrecLI agree tocomply withal)cityand county ordinances and state lW,h
PERMIT ISSUANCE FEES PAID:relating to building construction,and hereby authorize representatives ofcity to enter upon the above.men0oned property for Wpection puro.nERORADDTOMECH.(We)agree to ave,Indemnify an d keep harmless the City of Cu proDate agaWt liabilities,judgments,notes and expenses which may in any way accHANDLING UNIT(To t 0,"CFM)against Ity in conaequenceofthegrantingMthl. It.� //J FIANDLING UhTf(OVER IO,000CIM) CONSTRUCTIOSigwture of AppOcant/Contractor BateAusT Hoop tvY/DUCT) CONSTRUCTIOHA7AARDOUS MATERIALS DISCLOSUREWIIl the appllont orfuturc bulldingompant store orhetole hazardoTING UMT(T0100,000 BI1J)material as defined bytM Cupertino MunicipalCodn,Chapter 9.17,and thDate HeilthandSafety Cody Stolon 25532(.)7 'f1M1G UhTT(OVER 100,000 BTU)❑Yrs
Will the applicanto ildug ocmpantme equipment or devicTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazarousair roma mlmnt9a,de0ned by the Bay Area AirQualityMawgcmrn'tDity'c�7 ER-COMPQHPORI0GDMBTU) r D
4 YrsICINnhave read tti smatcrlalsrequime nuunder Chapter6.95 oER-COMP(OVER 100,000 BTU)theCaliforo aHealth&SafelyCode,Sctions 75505,25573 and 25534.Iuntlersundtheit the building does nol arrently haveatenanr that itumRESIDENTIAL MECH. SQ.FT gEp 10 1992
ibility ntiy the occupant of the requirements which sthemrea mfiateofOctapancy.
,5 ineror au ori ntir vsaT en IIIYUDateTOTAL: ISSUED BY
OFFICE COPY