20134 LICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B•Ilam P.a ed Identifladon I P 2MIT NO.
rna_ S 20134
I'ture:
' CITY OF CUPERTINO-BUILDING DIVISION
le tactoleName: Lk.Na APPLICATION /PERMIT
BUILDING-ELECTRICA MLIMBINC-MECHANICAL CATEGORY CONTROL
'TOR .Ac Jmot/Eoglneen Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address,
PFRMITISSUANCE ❑ ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION
RAW
hemby offirm that lam llcenaed under provlal..fC1bapter9(rovunenc APPILIANCESRF9DENIAL JOB DESCRIPTION
Ingwlth SeGlon7DD0)of DwEdm3 ofNeBuslmaeand ProfeW«aCnde,and roy
licenre V In full roe and effmRC PANELS 1.
Date It, Contractor J• t � SO`�iC�
ARCHITECTS DECLARATION 2M-I0D0AMPS
0'Z I understand ,y plaru,lullbeused as P.rbBc moria. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
COC
U Llan°d Pmfe®bral SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION ST]ECALCIRCU17/ .
70
tp.., Iherebya(Brm that]cum exemptfromthe Comactor'a License Lw(«the
O�Fpppp following nason.(SMlon 7mlS,Bualnea and Profewbra Code:Mydtyn Tom.,METER OR PO INST.
p;0 muntywhkbrrqulrnapffMt mtutr MOter,lmpmve.demol�h,orrepalr
anystrodunprbrt ilt ame al requimtheapp0antforeuchpermdto POWER CES
gg file a signed aatemnmt that he es B¢n ed punuant to the provbbra d the
Exx w(� Contndola lkevel�w(Clupter9(mnurcndngwMSetbn7000)o(DIW-
FEl slon3ofthe Bumnessand Profeaabr e)orthrthebexempt Nerc marti SWA1 L C VALUATION
p Son x.77 the baste for the alleged exemption. Any violation of Saabn7fp15Iy any
51:165 aPPBcantforaper. au *j theapperuutoadallpe 4dnnrrorethan 0 Tr-10- �
w E5 five hundrd]dollars($50).
❑I,as owner of the property,or my a npkyen with wage as tMlr sole NEW �. SfOW ES TYPE CONSIRIICTION'
C < romperuardon,will do the work and thestrurnam is not Welled or offered for
5 ❑ sale(Sec 70K Bushes,and Prdmbru Cade:The Cardvd.e.Llame Law
[� does not apply to an owner of property who bulda or Improves thereon,and
FS^ who doessuch work himself orthwgh his own employees,provided that such OCC.GROUP RES.UNITS
Improvements are not Intended oroHenni f«sale.If,however,thebulklingor TOTAL:
Lnprovement h sold within oneyear ofcompled.r,,the ownerbudderwUl have
tr�p.,rden of proving that m did not build or Wprove for purpose of we.). Qn. PLUMBING PERMIT FEE FTgpI)ZONE APN
"C as owner of the Property,am exchulvely contacting what 14enxd
contadors to mnatrud the pmject(See7016,Businem and Profea;brm Code: EMIT ISSUANCE
The Contactor'.Lim.Lw don not apply to an owner of property who ALS-DRAIN&VENT-WATER(EA)witch or Improves themon, and who mrtrar.4 for°ueb piojam with a
1gtBPtt01(a)licensed pursuant to the Ca,tada:Liters,Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
UI .m exempt order� B&P C for this reasonOUTSIDE FEES
' er Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
RECEIVE
WORKMAN COMPENSATION DECLARATION FD(IVRFS PER TRAPSCHOOL TAX Y_ N
❑I hereby affirm that I have a osmflaw
te of consent to self-Ire,a a —
oertlflam of Wnirken'Compematlon lesuana a a crrtlfled copythereof(Sec. RECFEEpr
3800,IAb C.y GAS EA.SYSTEM-11NC4OUTLE15 PARK FEE Y_ N
PdkyY 3 S I GAS EA. RECEIPT
Com^ °^Y 4( nZ BUILDING DIV]SION FE ES
Cedlfled copy V led Mthme cuty GREASE/INDUSERL WASTE BVTFRCEPIOR PLANCHECK FEE
�cedtned copy v nits,with m<dty Impeebn eiwlun.
CERTIFICATE COMP E TIPf10N ER WORKERS GREASE TRAP
COMPENSATIONINSURAN PAID
INSURANCE ate RCmI tM
(fhlaledlan neea not be cm
opleted BM pe
trmHit faore hundred dollar SEWER,SANITARY STORM FA.200I7
a1 mcerldly)«lean.) WATER HEATER W/VFNT/E.ECTR FNERGYFEE Y N
Ill-- rnplhat oy ne anperf.fian thewak for toohcorre,this molds]tared, —
1 slake no empen any person N any manner at u to bmome subject to the WATER SYSTEM/TRESIING
w«kua•comperuatbn Lova of cyBarrtu^.Date PAID
O Z nppBcant_ NEW RESIDFIJTIAL PI.MB. sQ.F'r. Date Remi tit
Z Q NOTICE TO APPLICA I:IL.fler making this cetiloteof Exemption,you
should bemme.ub)ect to the Workers'Comperurtbn pox sioa of the Labor TOTAL
N Code,you must forthwith comply with such profidaru or this permit shall be - ^
W seemed tewokaa
BUILDING FEE
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby toric f that iMrt b a er uwctlon],Ming agency 1-
tM perform ELECTRIC FEE
7 Z ante of tho Lende .Narne farwtachthis perrNtie Lv]¢d.Qet'3097,CI.C.) TOTAL
LLLe"dels Name PLUMBING FEE
LL0 Le mAffythatl QTY. MECHANICAL PERMIT FEF MECHANICAL FEE
O W Iantlfythatlhave Plthlsa -UB ynaMetatethatthea..ndeatelws
a drornd.]agree to comply with aBcayand muntyordlnanas and rtatelawa PPRwr usvANCE ;FEFSAID:dtytenteroortyforInnpur /C��Zdt(We).gmet.tveindhe e-menbrcd lampertyf«Wpttilon purposes. ALTERORADDTOMETH. e' Recel t#
(We)agreetocovebdemntyand keepharMentheCityofCupedWnssaijCttyIt, enteOnonhilAIR HAN13L1NC UNIT Gro lo,000 cFM) SUBTOTAL:gaimtsal CkyN mnaeue«e of the granting dthls pemt� 'el/`F 10v AIRMAN1wNGUNIT(OVFRIo,000CF�) TRUCTION TAX
Signature of Atpp�/on�or µ pec EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheappli mafuwmr fldingomnpantAomorha khavrdous' HFATINGUMr(10100,000BTU) Dale R2CE1 t#
material ea defined bytM Cupertlro MuNdpal Code,Ch.pter 9.17,and the
health ardSafety cot5&tn lin 2S532(a)7 HEATING UNIT(OVER IM,000 BTU) TOTAL:
I—I
Yen }s/ No
Blihe.ppBran« Nre wilding omrpantuae th,Buy Area
Air VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
.wh:chyWt lavrdoua air mnlamW one as deflond by tM Bay Arca Ab
Qualhy Muwm
geendd7 ROLLER-CVMP QFN000 OR 100, BTU)
Y
PAA RRRVI
q n No
love read the h oua outedab requimnients under Chapter 6.95 of BOII.ER-COMP 100,0000 TV)
omH
- theCali( iaealth&Safety Code,Sections,25505,7:533 and 25536. 1 , APR
understand that if the building doe;not currently have•tenant,that It l;my NEW RESIDENTIAL M.EC-L SQ17
16
rspun;iblllty to notify the occupant of the requlrefrent°which tryst be met
pd«lotaua da Cedlltate ofOCity of Cunartino
av
7rI-r� �cc �{��t
m
Owner or authod,ted agent ] Dat
TOTAL: ISSUED BY:
er'
OFFICE COPY --