19668APPLICANrTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY T
Building Pro'ect Identification -
rh firg Add.,,:
PERMIT NO.
19668
o
neva Phan
W&4Z
CName: Llc. No:
ose—`�
CITY
OF CUPERTINO BUILDING DIVISION
APPLICATION /PERMIT/q
A
/
CATEGORY CONTROL#
�ctor'e
Architect/Enginnan LIc No:
BUILDINGELECTRICAGPLUMBINC-MECIIAMCAL
QIY
ELECTRIC PERMIT FEE
BUILD G PERMIT INFO
Address:
PERMITISSUANCE
❑ ❑ 1:1LICENSED
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9 (commenc,
Ingwlth Sedion7OM)of DiWslon3oflhe Businessand PmfeulonsCode, and my
limnse la in fu foxy deffect.
Datef _CHIT7Eor
Date Contractor L Contr
RATION
I understand my pions shall be used u public records.
Am.hall Cued AS public
APPLIANCES -RESIDENTIAL
JOBDESCRBrIION
ALS
PANELS
OVER00AMf5
OVER 1000 AMPS
f/SQ. FE.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I hercbyafflrm that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/M
TEMP ORIDOL T.
following reason. (Section 70315, Business and Professions Code: Any city or
countywhich mquima permit tomnstmd, aitey impmve, de=lbh,or repair
any strumme prior to it. Lasuance,at.. requires the Applicant breach pertNt to
Ole a signed Statement that he is licensed pursuant to the provlslore of the
Contractor. License Law (Chapter 9(mmmenclag with Section 700D)of Divi-
slon3ofthe BusO mand Prof.toru Code)orthathebexempt Ihemfmmand
POWERCFS
N
SWI NE EC'RIC
'
VALUATION
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not mom than
OUM9qQj4CHI&FUTURES
/ .Q
NEW RESIDENTIAL EL
Ove hundred dollars (5500).
ni, as owner of the property, or my employees with wages as their sole
STORIES
TYPECONSIRUCTION
compensation, wllldothe work andthestmcture is not Intended or offered for
.ale (Sec. 7614, Business and Professions Code: The Contractor's License law
does not apply loan owner of property who Wilds orlmproves thereon, and
who doe. such work himself or through his awn employees, provided that such
OCC. GROUT'
REB. UNITS
Improvements arc not Intended oroffered forsale. IS however, lhebullding or
Improvement 6sold wlthinoneyearofe mplMiogtheowner-Wilderwill have
TOTAL:
t Men of proving he did not build or improve for purpose of sale,),
_1, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7D44, Business and Professions Code:
QTY.
PLUMBING PERMIT FEE
PERMIT ISSUANCE
PLOOD ZONE
APN
The Contractor's License Law does net apply to an owner of property who
Wild. car Improvea thereon, and who contracts for such ptojerts with e
mritractor(O hmnsed pursuant to the Contractor's License Law.
01 am exempt under Sec. B k P C for this reason
ALT'OR-DRAIN & VENT - WATER (EA)
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDEFITS
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N
RECEIPT If
Owner Date
WOO KMAN COMPWSATION DECLARATION
❑1 hereby .fit. that I have a mrtiBate of consent to self -Insure, ora
rertlflate of Worken'Compenutlanlmuranm ora mrtllled copy lhere.f (Sec.
3800, Isis C�'J�-♦♦ / /a
Poliq p ate• J G 2 `
SCIiOOLTAX Y N
RECEIT #
GAS, EA. SYSIFM-1 INC40UTLE17S
PARK FEE Y N
RFOEIPI
GAS EA. SYSTEM-OVER4(EA)
Cam an -a('`
nY (I ��, d#'1
CertiOc co ishercbyththeci
�Ccrtifled copy b filed with the city Inspection division.
BUILDING DIVISION FEES
GREASE/INDUSTRLWASTE INTERCEPTOR
PLANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thbsectioaneed not becompleted tithe permit bforom hundred dollen
PAID
Date Receipt#
SEWER.SANITARY-STORM E.A. 200I7.
(5100)oify that
Icl not lhatln the person nce many hewakfor
astob co eertbjeit ct tined,
I shall not employ any person in any mannerso a to became subject m the
Wcarlors'Gwe of California. Date
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
WATER SYSTEM/TREATING
plicanCompenutlon
NOTICE
NOTICE co MPLICANT: a after making this Cerinipro is Exemption, you
me subtectto the Workers' Such provisinprovbions of s famlit Labor
Code,shoulyou
Code, you must forthwith comply with each provisions orlhb pemNbhall be
deemed revoked.
Date Recel t#
NEW RESIDENTIAL PLM3. SOFT.
TOTAL:
BUILDING FEE
•�.7
SEISMIC FEE'
CONSTRUCTION LENDING AGENCY
I herebyaifim t hauhem bamnstructlon lendingageneyforthe perform.
ane of the work for which this permit b Issued (3ec.3097, Civ. C.)
lander'. Name
Lender's Addme
I certify that I have read this apphationand state thattheabove information
lammed. Iagree to comply with all cityand counlyordlnanm.and Statelaws
TOTAL:
ELECTRIC FEE
QTY.
MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEE$PAID:
relating to building construction, and hereby authorize representatives of thio
city to enter upon the abovcmentioned property fee inspection purpoxro.
(We) agree to use, Indemnify and keep harmless the of Cupertino
agaimtliabilities, }.idgments, meta and expenses Ina which rtuy in nywayaccrue
Against a lit City In consequence oft ant go unit•
ALTIRORADDTOMECH.
Date Recei t#
AIR HANDLING UNIT 9010,DW CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER IQOODCFM)
CONSTRUCTION TAX
SI rcofA lam/Commet Date
PP
EXHAUST IIOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
TING UNIT ITO 100,000 BN)
-
Wllltheappllca at or future building occupant store or band Is hazardous
materlai as defined by the Cupertino Municipal Code, Chapter 9.12 and the
IleahhAnd Safety CedaSe n25532(a)?
❑ Yea LNa
Wllltheappllcantoruturc building occupant use equipment ordevices
which .mit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
4Ycs
havernlaHeath&SafAtyCceriabrtIom25entsun3and21534.15o(
theunderstand to It I
ASafety Code,orcurr2550.5,ve
Date Receipt#
IIEATNG UNIT (OVER 100,IX0 BTU)
TOTAL:
O
VENTILATION FAN (SINGLE RFSID)
I$gI1AI�MDA•FE
IOC6/'i9R■
r5 tl1990
MOILER-COMP(3HIPORID0,000BTU)
BOILER -COMP (OVER 700,000BTU)
NEW RESIDENTIAL MECFI. SQ.FT.
If the bullding t haves
A tenant, that
that it
,
responbndynonehe
s..pact of the hick met
mponsibllllym ndlfythe ..pact o(the rcquircmentewhlch =at be met 21.
prior fssuancc ole Certl to naps racy
^
of..lPl�DQ
a•+*J y4
�'/a_, ,{
ISS11 14""b6 '
er or aulborimda t Date
TOTAL:
OFFICE COPY