23381 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building ProM Identification O.
PERM]TN
eQ °rero, Drs 23381
n re a
w Z� CITY OF CUPERTINO-BUILDING DIVISION - /^ ry 2-
1.0rat renlame: Lic.No; APPLICATION I PERMIT (• 7
kTI, S147S BUILDINGELECTMCALI'LUMBING-MECFIAMCAL CATEGORY CONTROL N
re ItM/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: I'F3U.9TIS6UANCE ❑ 1:1 �} ❑
LICENSED CONTRACTOR'S DECLARATION L�5
Ihereby
in.7000).f
0that'samsi.3.fheBusiprovisions olCsslms9de,and c APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth inful700D)o!d effect ofthe Bualnroeand ProfeedonaCode,end my
license is In(u force and d(cItt y PANELS
LOkenaSCh Ca ha�s�q/•s— Y /! lQ L/'/Lrl t ll•
UP TOMB AMSARCHITECTS DECLARATION 201-IODO AMPS
9z Iundentand my phos aMBbe used sspublic records. OVER IODO AMPS SQ.FT.FLOOR AREA 5/9Q.FT.
{*�yJ Licensed Professimal SIGNSELECIRICAL
OWNER-BUILDER DECLARATION SPFCIALCEtCU1T/MIST
z" 1herebyaflmothat i am exempt from the Contractor's License Law for the
following mum.(Section 71D1S,Business and Professions Code:My city or
O TEMP.METER OR POLE INST.
F„a coanlywhich requires isuNtbmrurequir theaplicamfrrolbh permit
tto
qqq any atmduretatertolta chat he Iscubo sed pursuant t the provisions
of
te POWER DEVICES
�a file a signed statement that 1u b licensed pursuant to the FSection 7000) of the
3w don 3 ofthe Liccalms Law(Cluprer9(commencingwis xamptherefofael- VALUATION
tithOs slon3olthe Business and Professions Code)orthat hebnxmpttherefromand SWIMMING I00L ELECTRIC
0 5 the barb for the alleged exemption. Any A.Iation of Section 7Q315 b5'any OUILETSSWITCHES.FIXTURES
applicant for a permit sub)ectstheapplicanl to a civil penalty ofnot more than
five hundred ndaNEW RESIDENTIAL ELFCTR
rs($500), SQ,FT. STORIES TYPE CONSTRUCTION
9.1 M I,as ow !the property,or my employees with wages as their sole
compensation,will do the work and the stmdure is not Intended or offered for
ole(Sec.7061,Businessand Professions Code:The Contractors License law
�$ does not apply to an owner of property who Wilde or improves lhereaA and OCC.GROIIIa RFS.UNITS
who does such work himself orthrough his me employees,provided that such
improvements are nae intended or offered for sale.If,however,the building or TOTAL:
Improvement is sold within one yearofcompletiory the owner-bu0derwill have
tlak.rice of prowling that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to construct the prejOt(Sm 7016,Business and Prefessiorm Code: PERMIT ISSUANCE
TM Contractor's License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pbojeda with a FEE SUMMARY
cgR(pctor(sI licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LI I em exempt under See. B k P C for this roasonOUTSIDE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
Owner Date RECEIPT It
WORKMAN COMPENSATION DECLARATION pp-{{/pEq PER TRAP SCIitX)L TAX Y_ N_
I hereby affirm that I have a certificate of consent to self.insure,or• RFCEB'T N
ce I mteofWorken'ComperoadmlmuranwaracertlllMmpythereofl5ee. CAS EA. INCA PARK FEE Y N
3300,lab C.) p y �n1„�_/ RECEPTM
P�Cml,fi
l 7Cnv (�1� GAS PA.SYSTEMOVER 4(FA) BUILDING DIVISION FEES
° ed copybherebyfumished. GREASE/INDUSIRL WASTE INTFRCFPTORPLANCHECKFEE
respy b llled with the city Irupectlon dlWelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANrFARY-STQRM EA 20OFT Date 'Recei ted
(Ihleacctbn need
COMPENSATION
Nthe INSURANCE
one hundred dollars
($1000arless.) WATER HEATER W/VENT/GSGiR ENERGY FEE Y N
I certilythat In the performance ofthework forwhich this permit is Issued,IL
label]not employ any person In any manner soas to become subject to the WATER SYSTEM/TREATING
Warkan'Compenutlon Gwa of Gll(omla.Date PAID
O Z Applicant NEW RESIDENTIALPLMB. $QFT. Date Recei tN
ZNOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,You
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=at forthwith comply withsuch provbims or this permit shall be BUILDING
LU > deemed revoked.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Be construction lending agency forthe perform TOTAL: s ELECTRICFEE
7 Z an.of the work lorwhlch this permit is Issued(Sec.3097,Civ.Q
V O Lender.Name PLUMBING FEE •
IL I— Ioedee.Address QTy-I MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedify Bunt have read thisappllcationand statethatthe above information -
N bcotrectlagreetommplywith andtyandcounty authom reperseand gate PERMIT ISSUANCE FEE 41D-.
Pt�Io- -�-
} relating tobullding romtmctlory and hereby authorize reprexntativro o(tbb La/�4
F Z city to enter upon the above-mentioned property for lupection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu part loo Date ReCeipttl
against liabilities,judgrarms,costs and expenses which may In any way accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this Fermi. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER IO,ODOCI•M)
Signaty re of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppBcant or future building occupant store or ha rad le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tit
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Healthand Safety Cud Ion 7553X0)7 HEATING UNIT(OVER 100,011(1 BTU) TOTAL: 1•
❑Yro No
Will the epplkant lure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which enut hazardous air contamlnants as defined by the Bay Area Air
Q.iallty Management Dct7 BOILER-COMP QHP OR 100,000 BTU's)
4 bt �Yrs Na
have read the hazy sus ma � � D
tonal,requirements under Chapter 6.95 of BOILER-COMP 100,000 BTU)
the California Health A Safety Code,Sections 25505,25533 and 75534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQA' WAR 26 1992
responsibility to notify the mcopant of the regWm
reenta which must be out
PI
issuance of a Certi(I sol ccupa racy.
Z, lgajALu- ��1S /r2 CITY UUr dam
Me,
or authorised agent Data a
TOTAL: ISSUEDS
OFFICE COPY