24342APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address: a
PERMIT NO 4 3 4 2
O O U2 S
neva anr:/N/g LVAD _O
CITY OF CUPERTINO�BUILDINC DIVISION
APPLICATION It PERMIT
/ n
L l�
Contractor's Na me: a tie. No:
{, 4_eZJ b 557-6 (
BUfLDINGELECTRICALPLUMBING-MECHANICAL
CATEGORY
CONTROL
Architect/Engineer. Lie. No:
tiCi e4.i %.`
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
PFIWTISSUANCE
❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions of Chapter 9(commm
APPIIANCESRESIDENTUL
JOB DESCRIPTION
PANELS
ingwith Section 7000)of Divlslon3 ofthe Buslnessand ProfesslonsCode, and my
license Is In full fo and dfect.
Limn Cha Lk. X
�a'trJr� �a.�_
k _
Date Contractor - (CS//S—
ARCHJTECTSDECLARATION
be
(understand my plain slaBb used as public reronls
UP TO 2DO AMPS
W /SQ. FT.
201.1
OVER lODO AMPS
OVE000DOAM
SIGNS ELECTRICAL
Licensed Professional
jj (]
PUTER
SPFLIALCIRCNT/MISC
OWNER -BUILDER DECLARATION
I herebyaffirthin I am exempt from the Contractor's License Law for the
rn
followingreason.(Sedlon7Ml.5,Businessand Professions Code:Anydtyor
cmntywhkhmquimsapermittommtmMc ter, npmve,dem lRh,ormpalr
anystm=mpMrtai hmancgaharequimtheapphuntfwauchpert tto
file a signed statement that he is Ilconsd pursuant to the provlsiom of the
u V
TE I Jj
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter 9 (commencing with Section 7000)of Divi-
$to.3 ofthe Buslnessand ProfessionsCode)orthat he isexempt therefromand
VALU.]yf]M
the basis for the alleged exemption. Any violation of Section7MIS by any
applicant fora permit subjects the applicant to a civil penalty of not more than
OUTLETSSWITCF IFSFI7CI'JRFS
�IM1.16W
coo
NEWRESIDENTIALELECIRFT.
�'
fivehundrddollara(SSM.
n L as owner of the property, or my employees with wages as their sok
STORIES
TYPE CONSTRUCTION
compensation, will do the work and the structure is nm intended or offered for
sale (Sec. 7044, Business and Profealom Code: The Contractor's License Law
does net apply to an owner of property who builds or improves thereon, and
who docssuchwork hlmselforthrough hlsawnempioyea, provided that such
OCC.GROUP
RES. UNITS
Improvements arc not Intended proffered for sale. If, however, thebuilding or
TOTAL:
Improvement issold withinoneyearofcompletion,the owner-buaderwill have
tf) nfirn of proving that he did not build or improve for purpose of sale.).
Lf L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professlov Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law does not apply m m owner of property who
builds or improves thereon, and who entracte for such pkojects with a
6.ctor(s) licensed pursuant to the Contractor's License Law.
u I am exempt under Sec B lea P C for this reasonOUTSIDE
yyq� DRAIN k VFM WATQt (FA)
FEE SUMMARY
BACK FLAW PROTECT. DEVICE
FEES
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY RECEIPT
Owner Date
P.a WORKMAN COMPENSATION DECLARATION
Q511 hereby affirm that I have a certmate of consent to sect -insure, or a
rtif toofWorkers'Compersttlonlouranre ora actlfled mpythemof(See.
3800, Lab 9_9,Z .^M�/�O
FIXTURES. PER .LRM ��
SCHOOL TAX Y_ N_
RECEBPI' N
GAS EA. SYSTEM -1 INC.4OUTLETS
PARK FEE Y N
RECEIPT
Pollryp Va.si
m any V
GAS PA. SYSTEM -OVER 4 (EA)
BUILDING DI VIS I ON FF. ES
CertNrd copy h hereby tehed.
0CertBied copy bfiled withh the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS
PAID
SEWER -SANITARY -STORM EA. 20QFT.
COMPENSATION INSURANCE
(rhlssecUon need one be completed If the permit Is forone hundred dollars
Date Remi t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
(5100)orless')
I rertify that in the performance of the work for which this permit Is Issued,
SYSITM/TREATING
I shall not employ any penwn In any manner so as to become subject to theWATER
WmlmWCompens.Ban Lawaof Califomh. Date
PAID
NEW RESIDENTIAL PLMB. SQdT.
Applicant
Date Recei t#
NOTICETO APPLICANT: IL after making this Certificate of Exemption, you
should become subject to the Work' Compensation provisions of the Labor
ers
TOTAL:
—
BUILDING FEE
731 ss—
Cadc, you most forthwith comply with such provisions orthls permit shall lx
deemed revoked.
CONSTRUCTION LENDING AGENCY
—
SEISMIC FEE
T T L ��
ELECTRIC FEE
Ihereby affirmthat there isacorstructiun kndingagemy forthe perform
ance of the work for which this permit Is Weed (See. 3097, Civ. C.)
Lenders N.
lenders Addmes
1 certifythat I have read thlsappBaOonand sate thattheabove Information
coea. Iagreeto conplywah all cily.nd countyordloancesand state laws
@rn
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building mremndion, and hereby authorlu rcprexNatives ofthls
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d krep harmless the City of Cupertino
.,.Inst Ihbillties judgments, cos . and expenses which may In any way accrue
ALTFRORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM(
SUBTOTAL:
against mid City in consequence of the granting of this permit'
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Signaure of Applicam/Com.efir Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harandoos
HEATING UNIT CIO 100,000 BTI])
Date Recel t#
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Cion 75532(.)7
O Yes No
Will the xpplkant orfs re building occupant use equipment or devices
which emit haramlous.ircotamlranb as defined by the Bay Arc. Air
Quality Mawgcmentsct7
FF�I Yes No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
PAID
BOILER -COMP OHP OR 100,000 BTU)
BOILER -COMP (OVER l0(LpDD BTU)
Th.vc.dthehaarousmateri"1 mquuxnrntsu crChapter6.95of
OCT 14
the Cali Ise licalth AS.f d SMlors 75 3 rad 75574.]
1992
NEW RESIDENTIAL MECH. SQ.FT
and tan hatlfthe g nm erre haves na t,lhatRkmy
nsibil yto nm th c rat of quircrrrn hlch most be met
P orom' anre a fi D
rant
�`t.ntBVV
�Cy�I.IX.Y�ur
ISSUED BY:—D6f �\
draDore agent Dae
w
TOTAL:
L
OFFICE COPY