22017 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification - PERMIT NO.
BuBdoi�i Ah 22017
XZa/ImO/e: B one:
f/l/SKY <l RY�`SVS*Z12S7 L6S'S CITY OF CUPERTINO-BUILDING DIVISION
^tractnN
' ame: Lic.Nn APPLICATION /PERMIT `lei 1
CL [S-TwG CS3 zzo 39e BUR,DINGELECTMCAIML BINGM HAMCAL CATEGORY CO
�/ Architect/Engineer. . Lk.Nm
QTY ELECTRIC PERMIT PEE BUILDING PERMIT INFO "
AddrtSF'S�y/Q/(�jlA`� PER)ATISSUANCE �7�y .
LICENSED CONTRACTOR'S DECLARATION fig
Ihereby afllrm that l sou Ecensed under provisions of Chapter9(comment, APPLIANCESRESIDENr1AL JOBDESCRR'HON
ingwith Smtlon7000)of Dlvldon3 ofthe BuslrmsandrmtesslonsC-odc and my
lire.Is In full once and died. PANELS -. I '
Lirenao Cbah LIeM .'Z ,� P�1r
Date Contnamr ,(s�y9'
ARCHITECTS DECLARATION 2014000 AMPS
MZ I understand my pizrs shall be used as public records. OVER 100 AMPS SQ.FT.FLOOR AREA 5/SQ.FT.
❑O
tj Limned Professional SIGNS ELECTRICAL
Ikg+ OWNER-BUILDER DECLARATION SPFC]ALCRiCU1T/MIST
z �a IherebyafBrmthatiamexemptfromthe Contrad.e.Llcenm Lwforthe
02oo q❑ following reason.f5emon 78115,Business and Professions Code:My city or
,-amuntywhlchrequ4 apermitrommbuMAter,lmpmwdemolbh,ormpalr TEMP.METER ORIOLE INST. '
`'0 37 anystmmm prbrto its Wuance,aborequimtheappllont forsuch pemdt to POWER p�q�q
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(mmmenctng with Section 7000)of Dlvl- 'XVALUATION aion3oflhegualnemand ProfesslonsCode)orthat hels exempt themfmmand 'SWIMMING POOL ELECTRIC CJLJ
Q.•]] the basis for the alleged exemption. Any violation of Stolon 78315 by any OU7LETSSWITCHE&FIX URES �1 v/�as�L
appllcam for.perrtd/subjects the appl cant to•civil pemlty ofnd mo a than
flv�undred dollars($5001. NEW RESIDENTIAL ELECTR SQ.Fr, STORIESTYPE CONSTRUCTION
Las owner of the property,or my employees with wages as their ante
compensation,will do the work,and theatructuro is not intended or offered for
0sa1e(Sec.7044,Budneas and Professions Code:The Contractors License faw
13 does not apply.to an owner of property who builds or improve thereon,and - s
.who does such work himself orthrough hisownemployeea,provided that such OCC.GROUP RES.UNITS
Improvenenb are nm Intended oroffemdfwmle.IL howewr,thebulldingmTOT
impmvementbmld MthlnoneyearofcompletioNtheowner-bu0derwBlhave ...
the burden of proving that he did not build or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
F1 4 as owner of the property,am exclusively mntraging with Ilrenseit PERMIT ISSUANCE �
contractors to construct the project(Sec.7014,Business and Professlora Code:
The Contractor's Llcesae Law does not apply to an owner of property who
Wilda or Improves thereoM and who contracts for such pipjem with• ALTER-DRAIN k VENT-WATER(EN
co
01ramorW licensed pursuant to the Contractor's License Law. FEE SUMMARY
U I am exempt under Sec B 4 P C for this reawn BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• Owner Date RECEIPT R
aryyea WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP - SCHOOL TA%_ Y_ N_
pl]hereby orke that I have o ]mum to of consent d self-insure,or a W RECEIPT M
cedUlab of Worken'Compeowtl°n Wunnceor•certBled copythereo((Sec. GAS EA.SYSTEM-1 C.4 OUTLETS PARKFEE Y N
3800,lab CJ
rdicyN tf 3M6pS7—Duey RECEIPT If
_ GAS.Fn.sysrFM
Com nv U f a a BUILDING DIVISION FEES
rcetified copy,Is hereby furnished. CREASE/IVDU L HECK FEE
&Certified mpy Is filed with the city Inspection division.
_ "CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 772M T�a��mc 4!
COMPENSATION INSURANCE SE}yBg- ARY STaaKlBaq.700Fr -a-7 ate ReCCI
(rhla stolon need not be complded Rthe permit b!.,orae hundred dollars aC
($100)or less.) WATER HEATER W/VENT/ELFOTA GY EE Y_ N
I notify that In the performance of the work forwhlch this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSDM/TREAITNC
Workcra'Compensation Uwsof CSBforois.Date - PAID
ZZ Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date Recei tR
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compensation provblom of the Labor TOTAL:
N Cade,you most forthwith comply with such provisions orthb permit shall be IN 4
W 7 deemed revoked. .
tl CONSTRUCTION LENDING AGENCY SEISMIC FEEI hemby afflrm that there b a construction lendingaprey,for the perform, ELECTRIC FEE
M Z anceoftheworkfor which this permit (Sec.3097,CIv.CJ TO
O Q lender.Name PLUMBING FEE
LL I-, Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE r�
O W I unity that l haw mad this apphe tion and dant that the above Nfomnatlon
11. Is correct,I agree to comply wlth all dtyaoW muntyoniinamm�andslatelaw. PERMIT ISSUANCE "�_ FEES PAID:
W relating to building construction,and hereby authorize representatives of this
Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD 7O MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Recei tri
O
against liabilities,0dgments,coda and expenses which may in any way accrue AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
agafrat said City In oxosixf err sof the grant lag It
jrfi ,�E 4� a-„-,��Q/ AIR HANDLING UNIT(OVER i 0000 CFM) CONSTRUCTION TAX
Signature of Applin /Contractor l•'Ya ' �s'— EXHAus r FIOOD(W/DUCI) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stoic or handle hazardous HEATING UNIT(TO 100,00 BTU) Date - ReCef tit
matcrlal a.defined by the Cupertino Municipal Code,Chapter9.IZ and the
Health and Safety Cade Section 75537b)I - HEATING UNIT(OVER 10,0008 1f TOTALN61 �-JO
❑ Yea No
Will the applicant or tune building occupant use equipment or devices VENR[.ATION FAN(SINGLE RESID) ISSFJAC&DTE
which emit havardousair mromicartsa.defined bythe Bay Area Air 1 D_ -
Quality Management Dbtdd7 BOILER-COMP OHPOR 10,110)BTU)
Yee ❑❑No NOVlhave readthebazardousmderiabrequlmmenbunder Ctapler6.95of BORER-COMP(OVER10,001ITU) N - 1aay9,
the California Health 6:Safety Code,Section 25505,25533 and 75534.1
undenta nd that if the bu dding does not currently have a tenant,that It is my NEW RESIDENTIAL MECHL SQ.Fr
responsibility to notify the occupant of the requirements which most be met CITY r oI. �Vrtk rl
prior to issuance of a Certificate of Occupancy.
Owner or authorlud agent Date � I-sa����\ � k
TOTAL' ISSUED BY:w✓a t^ `
OFFICE COPY