21661 'APPLICANT TO FILL IN INFORMATION VJkTHIN RED LINES— USE BALL POINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION - / .r.--e;
of me APPLICATION /PERMIT { 1
BUILDING ELECTRICALPLUMBING MECHAMCAL CATEGORY CONTROL N
ArcMtect/Engineer. ' ,. Llc,No
P,4RM1T'INFO
Address: - PERMITISSUANCE - ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
Iherebyaffirm that l am licensed under provisions of Chapter9(comrnen APPLIANCES-RESIDENTIAL JOB DFSC ON
ingwith Section 7(100)q(DIVlslon3ofthe Buel oars onsCode,and my
license le In o 1{./N dfea.---�� PANES 1' 1
Llrenae1;la�Lu.x blj i {w�V
Date 'ylL! Cantrector /' I1�/r '
ARCHITECTS TIO wT(.v 101-1000 AMPS` _
qm0 Z I enders nd my plaru shallbeused as public records OVER 10DO AMPS SQ.FI.FLOOR AREA $/�.FT.
q��uu OC
Fi (a Licensed Professkmal SIGNSELECTRICAL '
a� LGS OWNER-BUILDER DECLARATION SPECIAL UIT/M15C
Zip., 3 Iherebyaffirmthat l am exempt from the Contractor's License Law for the
F Z,F. following reason.(Section 70315,Business and Professions Code:Any city or TEMP. POLE S .a
county wh ich requires a perrmt ro mrutruct,alter,improve,demolish,or repair
q a a nystm=mpdortollsb ame,alsomquimatheapplirantforsuchpev tto ppWER I
E5 r rJ file a signed statement that he is licensed pursuant to the provisions of the a P -
W6 3 u, Contractor's License Law(Chapter 9(mmmencing with Section 700(1)of Divi SIy�MIVALUATION
alon3ofthe Business and PrefeaslonsCode)or that he is exempt therefromand _
O the basis for the alleged exemption. Any violation of Section 7¢115 by any OUTLE TC
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars($500). NE IDENTI ELECTR
ppyy I;as owner of the roe SQ.FT. STORIES TYPE CONSTRUCTION
(d••�n ❑ property,rty,or my employees with wages as their sole
compeasation,will do the work andthe structure b not intended or offered for
qsale(Sec 7044,Rumness and Professions Code:The Contmdot's Lt...Law
_ R does not apply to an owner of property who builds or improves thereon and
e•�"' who d...ehwork himself orthraugh Msown employee�,prov"Wthatsu6 OCC.GROUP . RES.UMTS
Improvements are not intended oroffered for sale.If,howeveMthebullding or OTAL;
iprovementlssoldwithinoneyearofcompletloNtheowner-bu8derwlllh e . te: -
tl�6,d;.nof proving that he did am build or improve for purpose of sale) QTy"%�; t :;P[� B i, ,E "MI yt ix ,,,'FEL`;,: ]7ppD?ANE APN
Lf L as owner of the property,am exclusively contracting with'limnud PERMIT ANE IPA �i1
contractors to construct the project(Sec.7044,Business and Professions Code: KfJ
The Contramm.License Law does not apply to an owner of property who ALTER-DBA
Wilds or Improves thereon,and who contracts for such pta)ects with a
ctx`�iFEE:SUM]\1ARYi%t
y�faors)limnwdpursuantwthe ContradofsLicense Law.
cot , y
LJ I am exempt under Sm ' 8 k P C for this .on RACK FLAW PROT T.DEVICE OUTSIDEFEES
Owner - Date - DRAINS FLOOR RJPF,AREA,COND. SANITARY Y N
. WORKMAN COMPENSATION DECLARATION - - - RECEI'Tp
❑I hereby affirm that I have a certificate of consent to self-insure,or FIXTURES.PER TRAP SCHOOL TAX Y N_.
certificate ofe 'CompeTuatlonlruu gLam If hereof(Sec. RECER'IN
3800,Lab CAS EA.SYSTEM-1[NC.d OUTLETS �� PARK FEE Y N
RECEIPT x
I'ollryp GAS F.A.SYSTEM-OVER4(EA) P - -
Com any " , BUILDING DIVISION FEES
.[�Certlfled copyle hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified mpy bfiled with the dty n
CERTIFICATE OF EXEMPFION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-57CJRM EA.200F1'. Date RelCl IN
(Thissection need not be completed lithe permit is forom hundred dollars
($100)arfe that
th) r WATERHFATERW/VENT/ELECTR ENERGY FEE Y N
Icetorlat in the performance of the work forwhich this permit bbased,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of Califcma,Date PAID
C' Z : Applicant NEW RESIDENTIAL"a. SQ.FT. Date Recei Ile
Z O NOTICE TO APPLICANT:If, making this Certificate of Exemption,you
'should become subject to the Workers'Compensation provisions of the Labor - TOTAL:
~ N Code,you at forthwith cwnply with such provisions or this permit shall be
- LU 9 deemed ked. BUIL NGFEE
eemerevoked. '
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there is a construction leadingagency for the perfarm- a ELECTRICFEE
Z an of the work forwhich this permit is Issued(Sec.3097,Civ.C.) TOTAL
OO tender:Name PLUMBING FEE
F Lender.Address - - QTY.':`•) 114E,'•HANI'l'A[.•:`P,ialiMI'C.yrt,. m•'t3�'FE .:;i
O W Icertltythatlhave read thisappUmtlonandstatethattheaboveinformation ' - MECHANICAL FEE•
IL iscor A agreeto complywith all dlyand countyordlnances and state laws PERMITISSUANCE �,?j�. FEES PAID:
} N relat building covet ,and herebyauthorlae representatives ofthis ,
ity repos the abo Honed property for inspection purposes. ALTFRORADDTOMECH.
Z .t to save,i e 1 and ep harmless the City of Cu ertlna /� ' Date ReceiptN
V ga illties,judg tx ands noes hich may inanywa ac e y AIR HANDLING UNIT(TO tO,;f CFM) ` SUBTOTAL:
111 al
Cityi.Mn u fun, a this permit.
AlR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX I
Signa reof Applieant C 5rt" D e EXHAUSTHOOD(W/DUCT)- CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS IN URE "
Will the applicant or tutu n handle havardous HEATING UMTLED 100,W0BTU) Date Recei [N
material as defined by umctpal de,Chapter9.11,and the '
Health and Safety Code Ion 25532W)7 HFATWGIJMT(OVER t00,OfA RTU) TOTAL:
❑ Yea No •
Will the applicant or future building occupant use equipmenicedrokes VENTILATION FAN(SINGLE RESID) DATE
which emit haeardous air uentamluenta a defined by the Bay Area Air
@+ lily Management District? BOILER-COMP C3tm OR 100,000 BTU)
Lthelallcalth&
n1�Noad the hazard materials requlremenN under Chapter 6.95 of BOILER-COMP(OVQt 100,000 BTU) =j(1N � �f ode,Sectiore 25505,25533 and 25534.] - Y'�thatifthe ilding bean currentlyhave a tenant,thatltbmy NEW RESIDENTIAL MECHity to ndif t Deco ant the req rementsivhichm thtu8nce da Ica o panty
Owner or aulhonad agent' ate /1 ISSUED BY:
TOTAL: W
OFFICE COPY