22984APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building project Identification
Building Address: -
bis
PERMIT NO.
/�
G G �yi Oji(
assn:Ilh.A.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
Comractors Name: LIo. Nee
BUILDING-ELECTRTCAL-PLUMBING-MECHAMCAL
CATEGORY
CO OUNNI�R �—
QTY ELECTRIC PERMIT FEE.
BUILDING PERMIT INFO_
Addeas. Uv MIM Ab ?Fe,*4
PERMITISSUANCE ..�
LICENSED CONTRACTOR'S DECLARATION
'
I hereby affirenthat lam licensed under provisions of Chapterg (comenscru,
ingwith SAdkm7000)of Divisioe3 ofthe Businessand ProfessionsCode,and my
Lletime. lChes fora and Affect.
Lontr
APPLIANCES -RESIDENTIAL
U BDFSCRI''DON
` C
pt�� lQ�
PANELS
DcenseClam
Date Contractor
UP TO 200AMPS
701-1000 AMPS -'
ARCHITECTS DECLARATION
I understand my plaroshall be used As public record.
OVERIUX]AMPS
SQ. Fr. FLOOR AREA
$/SQ. Fr.
SIGNS EL
Licensed Professional
^r�H1t�g
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Cent "does License Law for the
SPECIAL C
T
6 VV
s
-
TEMP. ME
following mason. (Section 7031.5, Business and Professions Code: Any city or
muntywhichrequireapen ttommtmd,alter,Improve,de=l0 h,ormpair
anystructure priorto its issuance,alsorequiresthe applicant for such permit to
file a algned statement that he is licensed pursuant to the provislors,
Ceelmene'e License I..(Chapter 9(mmmardng with Section 7000) of DWI-
Alan 3 ofthe Business and ProfeselovCodc) or that he lserempt therefrom and
the basis for the alleged exemptlon. Any violation of Section 7031.5 by An
Applicant for a permit subjects the applicant to a civil penalty of net more than
POWER DEVICES
vc,I
SWIMMING
��
UILEISSWI7CHF$flXl'URFS
VALUATi N
n ' Q ^e
(_ D
NEW RESIDENTIAL EL ECTR `"Q'FT.
five hundred dollars($500),
nn
1, as owner of the property, or my employees with wage as their sole
STORIES
TIPECONSTRUCTION
compensation, will d o the work, and the structure is not Intended or offered for
sale (Sec. 7044, Business and Pmfeadors Code: The Contractor. Llcerse law
TCF ,
does not apply to an owner of property who Wilds or improves thereon,and
does such work himself ortheaugh his own employees, provided that such
Improvements are not Intended proffered for sale. If, however, the building or
Improvement issold within one yearof completion, the owner-builderwlll have
OCC.GROUP
RES. UNITS
t en of proving that he did not build or improve for purpose ofsale.),
As or of the property, am exclusively contracting with licensed
c ra ms to mretre ct the project (Sec 7044, Business and Professions Code:PERMIT
QTy, PLUMBING PERMIT FEE
ISSUANCE
FLOOD ZONE
APN
Contractors License Law does not apply to an owner of property who
Wilds or Improve thereon, and who contracts for such pwI n with a
cgn((aec aor(s) licensed pursuant to the Contractor's Lioness Law.
LJ I am exempt under SB & P C for this reason
ALTER -DRAIN & VENTWATE4 (EA) %e
BACK FLOW PROTECT, DEVICE
FEE SUMMARY
OUTSIDE
DRAINS FIGO ROOT, ��
R AREA COND.
PER •DLV'
SANITARY Y N_
X
RECEFIXTURES
Owner Date
WOR"ANCOMPEIVSATIONDECLARATION
[31 hereby affirm that I have a mrtlficete of consent to self -Insure, ora
CJ aof Worken'Compersatlonlrsunnaora ceni(led mpythemof(Sec.
3800, Lab
l
SCIi00L TA% Y_ N_
RECEIPT N
GAS FA SYSTEM -1 INCA OUTLETS ��
PARK FEE Y N
Policy p
Policy
RECEIPT X
GAS F.A. SYSTEM -OVER 4 (FA)
Com any
BUILDING DIVISION FEES
�
Certlfied copy is heed with he city
�Cenifid mpybfiled with the city Inspection dlvlelon.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHE -E lei`I jII
i �l.D
GREASE TRAP
CERTIFICATEOFIIXEMPION FROM WORKERS'
COMPENSATION INSURANCE
Rhlasenion need era he completed lithe permit is forme hundred dollars
P Date Recti Nc�
SSR -SANITARY -STORM EA200FT.
(8100)oifyth permit Is Lssud,
Ice net that Nthe p PA.. in o(thework once. which As
I shall not employ any person In any once ao cue to become subject to the
W lawn of California. Date
WATER HEATER W/VENC/E.ECIR
E
I�
PAID
WATER SYSTEM/TRFATING
Applicant
Applicant
NOTICE
NOTICEco esubjCt to arkfter nukingthissation Certificate oft of the
Compensationprovisionsofthe Labor
Code, became subjectto the ply with
Cede,yme.kefMhwith comply with suchproviaWmorlhb permit hall be
deemed revoked.
Date Recei til
NEW RESIDENTIAL PLMB. SQFC.
TOT/iL:
BUILDING FEE `C.
SEISMIC FE FN40
CONSTRUCTION LENDING AGENCY
Thereby affirm that there At a construction lending agency for the perform,
ance of the work for which this permit Is issued (Sec. 3099, Civ. C.)
TO '
ELECTRIC FEE l•
lenders Name
Landers Address
I cenifylhat I have read thisapphatkmad katethattheabove in(omutlpn
Is correct. I agree to comply with all etyand county ordinances and state laws
QTY. MECHANICAL PERMIT:FEB,
PLUMBING FEE �•
MECHANICAL PEE �e
' PERMITIS5UANCE ��
FEES PAID:
relating to building destruction, and hereby authorize representatives of this
city to enter upon the abova-mentioned property fee inspection purposes.
(Wer) agree to save, Indemnify an d keep harmless the City of Cupertino
against liabilities, jodgments, coke and expenses which may In anyway accrue
phutsald Cityin s era he grant lift sperrnit.
VWLX�Ignaturc of Applicant/Contractor ??
ALTIRORADDID MECH.
We Recei tic
AIR HANDLING UNIT (TO 10,000 CFM)
I SUBTOTAL:
'
AIR HANDLING I/NIT (OVER 10,000 CIM)
IXHAUS'r HOOD(W/DUCT)
CONSTRUCTION TAX
CONSTRUCTION TAX PAID:
MAZA R DOLS MATERIALS DISCLOSURE
HEATING UMT(TO 100,000 BTU)
Will the applicant or(uture building occupant store or handle hazardous
material as defiecd by the Cupertino Municipal Code, Chapter 9.12, and the
_
Date RCC O
HEATING UNIT (OVER 100,000 BTU)
TOT
Health and Safety Cede Section 75532(.)?
❑ Ye No
VFNIILATION FAN (SINGLE MID)
ISSUANCE DATE
- PA i D
Wllitheappllcm or tum building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
El Yee ❑❑ No
BOILER -COMP DHP OR 100,000 BTU)
BOMERCOMP(OVER 100,000BTU)
Ihavercadthe ha s�riousmaterialsrequirementsunderChapter6.95of
the CaliforniaanHealth&Safety Cade, not a tend 25534. (
understand that nthe currently
era m requir haves tenant, that It
have
-
JAN 03 11
N[W RESIDENTIAL MECFI. SQ.IT.
theocgdoe
responsibility to notify theoavpant o(the requirements which must be met
met
_
prior to Issuance of a Certificate ofOccupancy, -
CITY Ut- LUPE I
ISSUED BY:
Owner or authorized agent Data
OFFICE COPY