24138 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building project Identification ` G-W t r is O PERMIT N2 413 8
Building Address: S LJJ���� 1
as,
uSe,SNams: ' �1 ''cc..-- � one:
APPLICAlIGNSUBMITTALDAM
G "f�`� s CITY OF CUPERTINO-BUILDING DIVISION /1xaaaa7g�,nL
Cnnlray�prV 5-:`c Lie.No: APPLICATION /PERMIT BUILDING-ELECTRICAL) ECHAMCAL CATEGORY CONTROL If
Archite m/Engineer: Llc.No:
.QTY ELECTRIC I VRmrr 'EE BUILDING PERMIT INFO
Address 2 "63 5fU4,y Q- 1j;1,1J /f%S'DU PERhBTI AN � ❑ NA
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am provisions under provons of Chapter9(commenc APPLIA CDENTIAL DLSCRIPI'ION
ingwith Sectton70M)ofDivlslon3ofthe Busim"s dPmfnslonsCode,and my t>�
license Is In fun force and effect. p
License Class Lt.If
Date Contractor
ARCHITECTS DECLARATION ' \ 1ERI
q ( 1{\,\�\\yv\/' SQ.I•T.FLOOR AREA f/SQ.FT.
q��uu ce0W O I understand my platy shag be used as public or a. OVER 1000
jX Z�j Licensed Professional SIGNS
< OWNER-BUILDER DECLARATION SPECIA CUIT/M `•-
7e, 5 I herebyefRrmthm Iareexempt fromthe Contractor's License Lawforthe
followlog reason.(Section 7031.5,Business and Profession.Code:Any ctty or
O H TQdP.M OR EINST.
F� munlywhich equlre.apermittommtmm,alter,Improve,demlbh,orrepalr
g
O 1+ m
g8 anystructureprlortoltsbance,a bo requires the applicant for such permit to ppy/ER DEVI
P� file a signed statement that he Is licensed pursuant to the provisions of the
3t4� Contractors License Law(Chapter 9lem.scingwith Section 7000)ofDiv,- y-W,gd� �OLELECfR1C
vs, Mon3ofthe Buslnessand ProfessionsCode)orthat he besempttherefromand VALUATION
y�" the basis for the alleged exemption. Any violation of Ste loss 70115 by any 0
applicant for a Fermat subject.the applicant to a civil penalty of not more than ''ISSWITCHLSFIXTLRES _f
cp; 52
five hundred dollarshepr. NEW RESIDENTIAL ELECTR SQ.FT, STOIi115 TYPE CONSTRUCTION
O..�n ❑1,as owner lithe property,or he employees with wage as there tyle
O .r;p satloZ u dothework,and coot ucturch lid Intended orofferedLfar
doe(Sec.appy Bu an
df lampeoru who
Wilds Contractors Licenseelad
$ don not apply torn ownerofthroug his o .empoyee,provided
that such
who doeseuchwork himsel(orthroughhlsownempioyeee,provided thatsuch OCC.GROI/I' RES UNITS
Improvements are not intended c roffered forsale.11 however,lhebulldingor 7
,mpro-7�LL Weeld withinoneyearofcomplelloRtheowner-b gderwill have
t1�J,xVdfnof pmv,ng that he did not build or Improve for purpose ofsele3. QTY, PLUMBING PERMIT FEE FLOODZONE APN
1 L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7064,Business and Professloru Code: PERMITISSUANCE
The Contractor'.License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or mp'rovn thereon,and who contract/ for such plo)ecb with a FEE SUMMARY
or(s)Ilcensed pursuant to the Contreme'.LlrenseLaw. BAIX PLOW PROTECT.DEVICE
1 am hemp under Sea B k P C f this masonOUTSIDE
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
—� Owner Date - REC®rl'N
W AN INSATION DECLAR 1 FIXTURES PER TRAP SCI IDOL TAX Y_ N
❑i hereby !firm that[have a certificate of consent to sef-inwre,ora RECEII'1'N
rertifimteofworken'Comperssetlonlnuranc.oracertNedcopythereof(See.
3900,lab CJ CAS EA.SYSTEM-1 INCd OUTLETS PARK FEE Y N
Policy RECE117 N
Co y GAS EA.SYSTEM-OYFRp(FA) BUILDING DI VI510 EES
Mann filed copy ist hereby furnished, G .E I lit w sTE INTeacFrroR PLANCHECK FEE `_
r-1Certifiedcopy b filed with the city Inspection division. IpQ
CERTIFICATE OF EXEMPTION FROM WORKERS' G Y' L„ PAID
ff TJ
COMPENSATION INSURANCE g _ # Q Date L'cci assess'(Thb section need net be completed if the permit b forone hundrod dollars
(f1m)mlesv) WA IlEA77RW / ICONSTRUCTION
FE' N
I certify,that in the performanreaf the work for which this permit b Weed,
I.hall not employ any person In any manner w n I, jeq.to the WATC2 SY
Workers'Com wsof Califorpla. Date ll
0 Z Applicant --////4i'/L//LYa-r s.�.. .7
Z O NOTICE TO I ANT.H,after makingthb Certlficateof Exemption,you NEW RESIDENTIAL PLMB, SQ.FT. Remi tk
should becons,sub,et to the Workers'Comperuatlon provisions of the Labor TOTAL:
F N Code,you most forthwith comply with such provisions or this permit shall be 'Uj j deencd revoked.d CONSTRUCTION LINDINC AGENCY FEEIhercbyaffirm that there b a construction lending agency for the perform- FEEZ annofthouorkforwhichthiapermlt Is N(see.3097Civ.C,) TOTAL:O znenaName / i G FEELL 1— Lenaer.Addrem QTY. MECHANICAL HERMIT' FEE ICAL E �^0 W Icertify thatl have read thisapplicationand matethttheabovelnformudonC Iscorrect.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE D:} relating to building construction,and hereby authorse representatives of this
Zcitytoenterupon the above-membned property for inspection purposes. LTERORADDTOMECH. �•(We)agree to save,indemnify an d keep harmless the City of Cupertino eceiptk
against liabilities,%rdgmente s raltapevawMeh may inanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) $U OTAL:again s id City s bftM granting of this peAIR HANDLING UNIT(OVER 10,(00 CFM) CTION TA
Sig to Appllc t/Contractor Data EXHAUST HOOD(W/DUC'D CONSTRUCTION TA PAID:
AZARDOUS MATERIALS DISCLOSURE
Ilthe applicant or future building occupantstore or handle hazardous HEATING UNIT(TO 100,00087" Date Recej
materalasdeRMdbythe Cupertln Municipal Code,Chapter 9.12,and the
I and Safety Code Semi 32(x)7 HE
UNIT(OVER 100,000 BTO TOTA
❑ Yes o
Millions pplicantorfuWmbuildingoccupantus.equipment ordevices VENTILATION FAN(SINGLE RESID) 155UA�N� •DATE
which emit havrdousairco to rants as cleared by the Bay Area Air
Qu=llty Management D000 BOILER-COMP DHP OR 1D0,000 BTU) SEP - 4
_rTl Yn o 1992
havereadthe hoar ousmatedalsmqulrementssender Chapter6.95of BOILER-COMP(OVER 100,000 BTU) 1�
the Gllfornla Health k Safety Code,Sectiore 25505,25533 and 25534. I N
understand that if the building does not correctly have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FI'. C'11 Ur V�I"CI'{I IIVU
resporuiblllly to nal(y the occvpa lit of th requlremenls whic ustb met -
Fri ort u lire ofa Ce atecd panty. q -
Owncrora cached ag vO Date
L �. ISSUED Be��!'4iMA�Z��
OFFICE COPY .