20039APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Project Identification
Budding Addrtm:
PERMIT NO.
^ n
23Soo cQi T.o Q.� UP, VNi�S � S PES
20039 0 O
G 3 9
Ownurr. Name mit
F-OZUKG-IZk7Up
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
A A
Contnden's Name: Lie Na
BUILDINGELEC'IRICALPLUMBiNGMECHAMCAl
77YCONTROL
Y
ArehttM/Engl r
Z r G -
QTV ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Add— � D K tGG � W S_r, S F,
❑ 1 IQ� El El
PERMITISSUANCE � is �
LICENSED CONTRACTORS DECLARATION
lkmbyafflrmthatlamllemseduMerpr Wmsof Chapter9(mmrcnc
Ingwit tbn7000)ofDMalon3ofthe Budrceaand Profew Cod and
Varus bIn fufi!orae and dfect.
APPWANCESRESIDENITAL
JOB N ^
�F, O />c
PANELS
Llarue Clam _Lk I
acr
Date CONm
T�
201-IODOAMPS
ARCHITECTS DECLARATION
IuMemua n%yplayshaDbeueedupubhctecm &
L —
OVERIODOAMPS
SQ. FT. FLOOR AREA
V90. Fr.
TRTal.
SIGNS ELECTRICAL
LI¢ased Profemlonal
SPECIAL CIACUR/MISC
OWNER -BUILDER DECLARATION
I herebyaffirm that I are exempt from the Contractor's License Law for the
TEMP. METER OR POLE INST..
following reason. (Section 70315, Buelema and I'mfeaiora Code,Any city or
county which requires a permit to comtruc, alter, Improve, demc4hh, or repair
any structure prb to its Wumcq also requires the a ppliant for such permit to
fib a signed statement that Is, is loosed pursuant In, the pmvLalom of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractors License Law (Chapter9(commencing with Section 700(B of Dm-
don3 of the Buslnem and ProfemionsCode) mthat he b exempttherdromaM
VALUATION
the bola for the alleged exemption. Any violation of Section 70315 by any
apph.t fora permit subjects the •ppReant to a civil penalty of not more than
OUT E SWPECHINSFIAITJRES
NEW R®EN11AL ELECTR SQ}T
aced ddlua 0500).
1, u ..c of the property, or my empioyeee with wages u their sole
STORIES
TYPE CONSTRUCTION
D
mmpewtlm, wlldothe work, andthestrucmre is cot Wended or offered for
ink (Sea 70K BuelrcssaM Prof.w. Code: The C.emact.e. Weenie Taw
does not apply to so owner of property who builds or improves thermq and
who dm such work hlmvelforthwgh his own employees, provided that such
OCCGROUP
RES. UNITS
Improvements ate not Intended oroffered fmssle. If, however, the building or
TOTAL: Qr
Impmvemont haold whhm omycarofcampletbn,theewner-bullderwlll Tuve
t rdenofpmng UuAhadidwb
tuudorimprovefmpurposeofsale.).
U1, vias owner of the property, am exclusively contracting with Bcoread
contract. tocoetruct the project(San, 70K BuslnrmaM Prdessions Code:
QTY. PLUMBING PERMIT FEE
FLOOD7DNE
APN
PERMIT ISSUANCE
The Contractors Liarue Law dm not apply to an owner of property who
Wad, or Improves themon, and who contracts for such pb Sojecwth a
c a�tm(a) licensed punvut to the Cmtractds Liceese law.FEE
El I am exempt under Sec B k P C for this reason
ALTER -DRAIN & VENT -WATER (FA)
SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY Y_ N
RECEIVE e
Owner Date
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have • certificate of eros. to seB-Iwre, m a
MnlBatofWarkernCm�p.nsatlm lnsunnaaaartBled mpythereo((Sa.
Mile, Lb CJ
a
pD(ITygps l'FR TRAP
SCHOOL TAX Y_ N_
RECEO'f
S F.A.M
GASYSTE-1 INCE, OUTLETS
PARK FTE Y N
RECEIPT S
GAS EA. SYShM-0VER4(EA)
C.
C.
Cany
BUILDING DIVISION FEES
Cerfilied copy is hereby furrdahed.
erllflM copy Is filed with the city inspection dlvWm.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E(EMPTION FROM WORKERS
PAID
COMPENSATION INSURANCE
crwarttknnr<dnabee« pinedlthepermtl.fmmahundreddoUm
Date Recti t#
WAII/
ENERGY FEE Y N
010(dorlm')
loertlfytlut iothe pedomuna afthewmk brwNch WepemdtVHvred,
Ishall not employ any peomr N any manner so as to became subject to the
Wo,lu,.' ComEx,.tlon Laws of Cadineola. Dale
I WA /I
AID
Applicant
NO TICE TO APPLICANT: H, after making rials Certlfiate of Exemption, you
Date Recei t#
NEWLPLMB.
I
\_
TOTAL:
should become subject to the WorYen' Compewtlm provistere ofihe Labor
Code, you must forthwith comply with such provisions or this permit shall be
BUILDING FEE
dimmed revoked.
-
SEISMIC FEE
CONSTRICTION LENDING AGENCY
I hereby affirm that there is a mrutructlen lending agency for the perform,
arse of the workfor which thin permit Is Issued (Sec_ 30 Y/, Civ. C.)
TOTELECTRIC
'O"
FEE
�L�=
_
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lenders Name
ienAerb Address
1 anlfythat I have read thbappllatbnaM stamthat theabove Wormelon
bcomed. I agrecto comply with all city and county ordinances and Yatelaws
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
Mating tobullding mntructlon, and hereby authorise representative of this
city to enter upon the abovntrcntbned property for Impaction purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu pertW
ALTER OR ADD TO MICH.
Date Reeei t#
SUBTOTAL'
ago Wt ilabNtles, judgnvrta, costa. M expaue which may In any way amu.
ago lint said City to conenq.,. of the grant Ing of this permit.
AIR HANDLING UNIT (70 10,000 CFM)
AIR HANDLING UNIT(OVER 1O,ODO CFM)
CONSTRUCTION TAX
Signature of Applicant/Contactor Dare
EXHAUST HOOD(W/DDCTI
CONSTRUCTION TAX PAID:
HA2ARDOUSMATERIALSDISCLOSURE
Will theapEdam or future building onvpart More or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
HEATIISG UMT(TO IOD,000 BTU)
Date Recti t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
O 0
I❑a And ail Safety Code, Section 255324)?
Yea No
Will the applicant or❑future bulldingoaVpannt use equlpnsnt or devim
VENIILATION FAN(SINGLE RESID)
ISSUANCE DATE
which emit haardoua air conambums as defined by the Bay Area Ab
Quality Management DlstrWi
4Ye ❑❑ No
have read the hazardous materials requirements under Chapter 6_95 of
the CGBfomla Health & Safety Cade, Secdom 2SMS, 25533 and 2S531.I
^.
�C 1(0C!i'IU
R
BOILER -COW OHI' OR IMAM BM
BOILER-ODMP(OVER 100,000 BTU)
NEW RESIDENTIAL M.ECH. SQFT
understand that B the building; does donot currently have x tenant, that It b my
,✓ IJJ
responsibility to notify the accopand of the requirements which oust he met
..
prior 0Isuance of a Cc1 to of paan[cyy.� /yWa)
r
�IIB
jr)M
ISSUED BY:
Owner or authorised agent Date
TOTAL:
OFFICE COPY