20550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
Building Addrtu; 20550
rn sate:
nePre [OMP(, one CITY OF CUPERTINO-BUILDING DIVISION
G era"° 'Na oue.N.: APPLICATION /PERMIT . 6
BLDING-FIECTRICALPLUMBINGMECHAhTCAL CATCCORY CONTROL Y
UI
ter/Fsglneer. Lk.No:
LL S�+J CIJ L SAS BUILDING PERMIT INFO
AM
q QTY ELECTRICPERMIT FEE
Address: O PERMITISSUANCE � f� ❑
LICENSED CONTRACTOR'S DECLARATION y�
I hereby affirm that l am licensed under provisions of Chapter 9(common APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Se l..7000).(DiNslon3ofthe Buslne.and Profeuloa.Gode,andmy
license Is In full force and died. PANELSLic
Date-ala Llcp
DatO6
eContnctor
ARCHITECTS CRATION 301-1000 AMPS
ce s2. I understand my platy shall be teed as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
oLicensed Professional SIGNSELECTRICAL
� 4td OWNER•BUILDER DECLARATION
a Iherebyaffimlittl am exempt fromthe Contractor's License Law for the SPECIAL CIRCNT/MISC
following reanon.(Senidn 70315,Buelner end Pro(e.bns Cade:Any ntyor countywhkhrequlmaPetmittomrutmd,alter,Impmv demoBsh,orrepalr 'Ti7✓.P.METER OR POLE WST.
C, —in
$ anystmmmprbrtoltssuance,aL requlmtheappllrantforsuchper tto
t51 5 file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Ole Contractor's License Law(Clupter9(commencing with Section 7000)of Divi-
SWIMMING IDOL ELECTRIC c
p�Os sion3ofthe Butlneasand Profeaov Cede)ortha[hebexempt thercfromand VALUATION
q the basis for the alleged exemption. Any violation of Section 7031.5 by any /'1
`
<X applicant for a permit subject.the applicant to a civil penalty of not more than OUTLETSSWI7CHFSFIXTUAES "r O
O five hundred dollars($500), V
Sn ❑I,as owner of 1M property,or memployees with wa s as their sok NEW RESIDENTIAL ELECIR �.F7. STORIES TYPE CONSTRUCTION
P Percy, Y Be
mto&c. 044,B.M.l do theworkand the structure Cod :The
not Intended or offercense Law O sale(See apply to ainow owner
fpmffProferay Code: Crint.d.or improves
License Law
does 3� whodotapply loanowner dprough who nemporimprwvided that such
OCC.GROUP RES.UMTS
EE wproveeuch ntsamwork himself dedorwferedhis owale.If envev,the dthatwrch
Improvement.arenot Intendedoro(fec forsale.If,however, gder ilI have L;
improvemenlbmidwlthlnoneyearo(compidlorytheowner-WEderwill have
tfLjNrden o(pmving that Mdid not build orlmpmve for purpose o(ukJ. QTY.AFD(TURO�PER
NGIEWU FEE FLOOD 7DNE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT
mntnnors m mmW ct the project(Sec.7614 Businc.and Ikofemloro Code:
The CmAurdoe.Limn.Law does not apply to an owner of property who ENT-
Wilds or Improves thenen,and who contracts for such pipjem with a FEE SUMMARY
cgRt(I or(a)II...d pursuant to the Cont.doe.License Law. IC D CE
LII am exempt under Sec. B&P C (or this reason
,A CO SANITARY Y N
Owner Date RECEIPT Y
WORK MAN COMPENSATION ftlfi DECLARATION SCHOOLTAX Y_ N_
I hereby affirm that I have•cerclflate of consent to self-insure,ora RECEIPT Y
mrtificne-(Workers Comp..atlon lnatran..ra ormfkd copythereof(Sec. GAS EA SY -11NC40UTL PARK FEE Y N
380D,Lab C.)
Policy Y GAS EA. ) RECEfPTN
Com any BUILDING DIVISION FEES
�CMiOed copy b hereby furnished. CREASE/WDUSTRL WASTE I EPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF FJ(EMPTION FROM WORKERS' iGREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.PpFT. Date Remi t#
(Thio section need not be completed BIW permit is for one hundred dollars
(S1 hife..)
I occeor le that N the pednr
ounce of thewark forwhich this permit is issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I shall not employ any person in any manner.as to become subject to the WAT[R SYSTEM/TRGTING
Worknrs'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date ReceF Iii
Z O NOTICETO APPLICANT:ILaher making this Certificate.!Evempthm,you
Fshould become subject to the Woricers'Compmuatlon pmvbiov ofthelabor TOTAL:
to Code,you at forthwith comply with such provide.or this pemJt.hall be
Wj deemed revoked. BUILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby.M that there is a construction lending agency for the perform, ELECTRIC FEE
7 0 armofthework for whkhthb permit bl�sued(Sec.3097,C1v.C3 TOTAL:
I,mder'a Nauk r r�� £ PLUMBING FEE
LL LL H Le.der'.Addm. QTY. MECHANICAL PERMIT FEE
O W 1cutifythat I have read thin appuationand rorm
te thaHheabovelnfoalon MECHANICAL FEE
IL bmrma.I agree to comply with all city and munty ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>- relating tobullding construction,and herebyauthorixe repeexntativeeofthis
W
U) city to enter upon the above-namlored property for impectlon purposes. ALTERORADDTOMECIL
_ (We)agree to save,Indemnify an d keep harMew the City of Cu Perrino Date Recei t#
against Rabilltles,Ildgments,mks and expenses which my in any way accrue AIR HANDLING TWIT CTO 10,000 CFM) SUBTOTAL:
rut eaidC sequence of the granting of this permit.
1"12 . 90 AIR IIANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
%Tgusion,of Applicant/Contractor - Date EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazard... HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as dented by CueIrw Municipal Code,Chapter 9.Q,and the �ry
Healthand Safety Code oon 35531(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: JI�
l Yes N
Illtheapplimrat .1 rebuildingcompantuse equipment ordevices VENTILATION FAN(SINGLE READ) ISSUANCE DATE
which emit h..rd.us ale roma nanisas defined bythe Bay Area Air BOILER COMP h
Qt lity Management Dtdtri DHPORI00,000BTU) n Al
4Yea o 0 BOILER-COMP 100,000 BTU) 7 1
1ay.mdthalth&r f materials ulrementsundar Cha U.1 of Jr4Y 1 b d
the Gllfomla Health&building
Code,Sen loris 3:505,ve a t and 35534.1
understand th9 If the building does notcortcntly haveatenant that ltbmy NEW RESIDENTIAL MECH. SQ.Ff.
nsporuibili y�n-tify the oompant of the require encs whichmusiberect
P to is �i cof rtlfcat fOcmpanry. � /s�ti—yycf.
�C(I��B
JaK�oCauthorixed agent ate TOTAL: ISSUEDBY:V d./V•�
OFFICE COPY