23419 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Buildina Pmert Identification PERMIT NO.
Build Ing Address: 1 Z 3 41 'V�t
0161 Ct4RMeo-j 124.
ams: oar:
R ' IS bG z.57 - "SSr CITY OF CUPERTINO-BUILDING DIVISION ^J' / 7
Contractor's Name: Lie.N'o; APPLICATION I PERMIT —•1
G�:C ✓e SZ OI Z- BULDINC-ELECTRICALPLUMBINGMECFIAMCAL CATEGORY CONTROL Y/,77
Archited/Engineer. - Lie N. O
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE FV, a ,
[hereby aHirmthat l am licensed under provisions ofChapter9(commrn AP1`UANCMRESIDENTIAL JOB DESCRR'17
tngwith SeMon7000)ofDlvi.lon3oHhr Bueinn.and PmfesslonsCo and my
license is in full force and affect. PANELS L y
Llaense Class — LACY SSI-A'
Date i Contactor UP TO 2DO AMPSe(�—'L/ l/l/l/Il �XJI•� TAY
ARCHITECTS DECLARATION 2014000 AMPS
(pw otOz I understand my phroahall be used as public records. OVER IOOO AMPS SQ.FI.bI.ODR AREA S/SQ.FT.
F Llcenssd Pmle®bursal SIGNg ELECTRIGL L�If / lI g
<�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/11 ^I/( `
z p., Iherebyaffiren that l am exemptfmmthe Contractor's License raw for the
qQ following reason.(Section 7m15, e:My cty or Business end Professions CodiE R
�4 'IT'
counlywhich requhesa permittororot m
ruct,eller,Improve,deollsh,orrepair TEMP.METER OR POL
anystmclure pdortoits Issuance,also requlreslheappaant for such permitto PCIWERDEVICES
file a signed statement that be b licensed pursuant to the proelms of the
3u.(� ConlnctorsLicense Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL n3E.E VALUATION o O
F�0:1 on I
eioofth.Bueineuand Pmfessione b Code)orthat he exempttherefromaM
GX the basis for the alleged exemption. Any violation of Section 70115 by any OUTLE'IBSwITC?ffSHXTURES
applicant lora permit wbjecbtheapphcantto•civil perultyMnot morethan
lly�hundred dollen(SSOII). NEW RESIDENTIAL ELECTR_SQFI', STO]pp5 TYPECONSTRUCTION
LJ I,as owner of the property,or my employees with wages as their sole
t a compensation,will do the work and the structure is not Intended or offered for
`t�`� ❑ sale(Sec 7044 Business and Pmfeesloiu Code:The Contractors License Law
K $ does Am apply to an owner of property who Wilde or Improves thereon,and
EEEE who does suchworkhlmseBorthrwgh his own employees,provided that such OCC.CROUI' RES UNITS
Improvements arc not Intended or offered for sale.IG however,the building or TOTAL;
Improvement is sold within one yearofcomplefoo,the owner-W ilderwill have -
t)Le,Zurden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD 7pNE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to censtmct the project(Sec.7044,Business and Profession Code:
The Cmdredori License Law does not apply to an owner of property who AL]ER-DRAW Ya VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pAojecta with a
co cuu(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
1_1 I am exempt under Bre B 4 P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR RODF,AREA,CONI). - SANITARY V N_
• Owner - Date - ftFLFIPC N
WORKMAN COMPENSATION DECLARATION Fp(gURES.PER TRAP SCHOOLTAX Y N
� ❑I hereby affirm that I have a certlBale o!consent to aeB-insure,or RECEIPT N
cedlllateofWorkeri ComperaxHonlneuranceaecertl(k:d copythereo((Set:
3800,Lab C.) GAS EA,SYSTEM-1 INCA OUTLETS PARKFEE Y N
1 Poliq# Llbs S 3S GAS EA.SYSTEM-OVER4(EA) RECEIPT
Com ray ST.nTQ JV BUILDING DIVISION FEES
edified copy is hereby furnished. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
' Certified copy Is filed with the city inspection dlN.lon. (v Y6• FO
CERTIFICATE OF h3(EMPTION FROM WORKERS' CREASE TRAP PAID-7-17—Y 67224
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(pPT Date Recei t#
(This section need not be completed lithe permit bforoae hundred dollars
(510U)orlessJWATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I certify that in the perfomunauf thework forwMch this permit is blued,
I shall not employ any person In any runner so U to become subject to the WATER SYSTEM/'TREATING -
Worker.'Compe®ation Laws of California.Dale PAID -'
Z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Dat¢ Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Comperuation provisions of the Labor TOTAL:
N Code,you moat forthwith comply with such pmviaione orthb permit shall be BUILDING FEE 72,00
W j dermad revoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
�hereby afRrmthwhiccrc ispermtn tion issurdrWec.309nry .C.) perform TOTAL ELECTRIC FEE
M Z once oflhe work(or wblch ibis permit is issued(Sec.3097,CIv.CJ '
. 02 Lender.Name PLUMBING FEE
LL F Land.,.Addrees QTY. MECHANICAL PERMIT E MECHANICAL FEE
O W Iadlfythatlhay.madthbapplatlonandrtatethattheabovelnfomatim
Boomed.I agreetocomplywilh all cityand countyordinances and dalelawa PERMITISSUANCE FE SPAID:
>. 1 relating to building comtmthor
ction,and hereby autze representatives ofthl. 2 4/.72x*
N
city to enter upon the abovementioned property for Inspection purposes. ALTERORADDTOMECH.
z (WO agree to save,indemNly an d keep hFarMeas the City of Cu Perrino - Date Recei t#
V again Id t judgere , A.end expetslg oh,thI. env anywayaceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Jpf AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
S Appllant/Contr or Date IXHAUS'T HOOD(W/DI1CT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Code Section25532(a)? - HEATING UNIT(OVER 100,000 BTU TOTAL
F1 Y. ,+�—,1 No
Will the applicant ca uture building occupant sail equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District?. BOILER-COMP OHP OR 101,000 BTU
4Ya ❑❑No
have readthrhavrdo..materials requirements under Chapter G95 of BOILER-COMP(OVER 100,000 BTU)
the California Health h Safety Code,Sections 25505,25533 and 25534,I LYY�� pg
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT P-A V D
responslbUity to notify the occupant of the requirements which must be met
priorto Issuance of a Certificate of Oce pa my.
. NIA 19 t �"a'r
Owner or aulharired agent Data - - 1 BY;
TOTAL:
OFFICE COPY