20793 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
1
Building Fro ed Idmd c tion
Buddln ddress: PI:ILW'T NO.
_ " ' 20793
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ERTINO-BUILDINGDIVISION ^� ^
Contractors Name: LIc.No: ICATION I PERMITCTRICALPLUMBING-MECHANICAL CATEGORY CONTROLNArchitect/Engineer. Lk.No:f �fCTRIC PERMIT FEE BUILDING PERMIT INFO
Address: /� /� LLUII
NCE 1 ON R'S DECLARATIONIherebyeHirtnthat temlkmeed under provielone of Chapter 9(convnrncESIDENTIAL JOB DESC ION
(nems,1.1.fell 7000)of DlWect. (the BuslnessandProleulona Codgand my �
Llcer lain roll fo roof effect. p'1 PANELS
Date JLCo.m.r N
ARCHITECT'S DECLARATION x11-1000 AMPS
rcO Zp 1understandm Plans shall be used as ublle recarae. OVER 1000 AMT'S g/SQ.F.
Y P P SQ.FT.FLOOR AREA
z Licensed Professional SIGNS ELECTRICAL
�<' ' OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
Ihereby affirmthal l sort exempt from the Contractor's License Law for the
p following reason.(Sedion 70315,Business and Prefmlons Code:My city or CT
K t'q county which requires a perent to comtroM alter,improve,demolish,or repair Tom' P.METER ORPOLEINST, L
7a anyatwcture prlortn Its isomm,-leo requireatheappBant/orsuch permit to POWER DEVICES
00µ6
µU file a signed statement that he Is Beensed pursuant to the pmvislom of the
3µ Contractor's License Lapursuant. with Section 7000)or Divi- SWDMINC POOL ELECTRIC
F, O slon3 ofthe Business and ProfesslaneCode)orthat he is exempt therefmmand - VALUATION
the basis for the alleged exemption. Any violation o(Sedlon 70115 by any !s ^ •n �—
<5 appUmnt fora permit subjede theappllcant log civil penalty of not more than V OUTLETSSWITCHFSFLVIURES `(p L`, Q
five hundred dollars(5500). NEW RESIDENTIAL ELECTR
�1,as owner at the property,or my employees with wages u their sole SQ.Fr. STORIESTYPCCONSIRUCTION
compermation,wRldolhe work,andthe stm=m b not Intended or offered for
O .1.(Sec.70K Buelnesa and Professions Code:The Contractors Ltd.Law
�E does not apply to an owner of property who builds or Improves thereon,and ['LIQ
whodoessuch work himaelrorthrough his own employees,provided that such J '1� OCC.GROUT' R}S.UNM
brprovenenbammn tendedorofferedformle.I(hmvever,thebuildingar TOTAL:
Mprovement bsold mthn.nays.ra(campldlon,the owner-bu0der w111 have
t"rdenoffmvingthat he did notbuild orlmprove rorpurpoeo ofsale.). QTy. PLUM NG PERMIT FEE FTpp ZONNE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT LSU
mntracme,to entered the project(See 7066,Business and Pro(mlmo Code:
The Contractor's License Law does not apply to an owner of property who .DRAT -WATER(EA)
builds or Improves thereon,and who contracts for such plojecb with a
aetor(Q Boensed pursuant to the Contractors Liwnee Law. FEE SUMMARY
I am 15exempt under Sec B la P C for this reason BA PR SCE
Owner DalF, GOND. SANITARY Y_ N_
e CEp
ate,/ WORKMAN COMPENSATION DECLARATION TRAP SCHOOLTAX YREW
— N—
Mr hereby af(Irm,that 1 have a certl/irale of consent to sell-Inwre, 1 RFxIIPT 0
3800,LA o!Warken'Comperuatlon Wurance ora codified ropythereor
38�YCJ�) [ ` ��� C EA. .1 W O �� PARK FEE Y— N_
C. 10 J/
RECEB'T p
Com n AS EA SY V )
Certified ropy V hereby mmiehed. BUILDING DIVISION FEES
�Certlfted copy b filed with the city Impaction division. C •/[ L INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE SEWER-SANITAR RM EA 20OFI. Date Rcmi t#
(TMneedd rabe completed dine permit Vfor arae hundred dollars
(f100)omrtayths.)
rfy rldtis WATERHEATERW VENT/ELECTR, ENE•RGYFEE Y N
Iat In the performance of the work for which w
hthis permit leled, '
I shall not Io any person Iota ny er so u to jest to the RIOTER BY workeriC yp]p,g on7(3Q•s at Ly/ate L PAID
O Z Appuaant e JVTU�1 Jf Hr (<
Z 0 NOTICE TO APPLICANT:H,after makings Certuwthl7— a ar Exempnan,you NEW RESIDENTIAL PLMB._SQFT. Date Recei t#
should become subject to the Workers'Compematlon provisions ofthe Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orlhis per it shall be
deemed revoked. BUILDING ,W
1 CONSTRUCTION LENDING AGENCY SEISMIC FEE _ a
Ihercbya(Rrmthat there is a construction lending agency forthe perform TOTAL: ' x� ELECTRIC FEE s�
7 ls
Z ance of the work for which this permit V issued(Sec.309],CIv.C.) ELECTRIC FEE CO
Tieenra
V O I<naer'e Name
LL F- Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImAifythatlh wmadthbapppotmnaMoatethatlheaWvelnfort tion
borned.I agree to comply with all dtymd countyordiamonsmd pale laws PERMTTISSUANCE FEES PAID:
} 1 relating tobulleling construction,and herebyauthorlu repmaentatfveso(this
F 2 dtytoenieru the above-mealien M property for bupedlon purposes. ALTER OR ADDTO MECH.
V — (We)a e t lave,Inde a p harmless the City of Cupertino Dafe Receipt#
agaWtll. tk Judgments, as pare.whichmaylnanywaya9eme AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
agalnstsa Cit in conaeque of the antingo(thls permit FI/f-`a7!(–/Y
AIR HANDLING UNIT(OVER 10,000CFM). CONSTRUCTION TAX
signam o pp0on o tractor 7 EXFWUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDOUS MATERIALS DISCLOSURE
WBltheappticm ormturebu0dinga pantetomorhanalcha rdous HEATING UNIT(TO 100,000 BM Date Recej f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and$a(etyCod l5gatlon 25532(x)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:
I1 Yes ny�(7"�j No
hichannithmad mmbuilding occupant useequipmentArea devices VENTILATION PAN(SINGLE RESIU) 1 NCE DATE
whkheManagement air con nsnlau defined byline Bay Arca Air
Quality Management Dbto o ROLLER-COMP DEB'DR 100,000 BTU) JUL
4 Yea N FO rr J U
have shah a us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Rifle.1th&SafetyCode, dmns25505,ve.te nd,thatI (Y Ofre d[..2tlyhaveatenad 255Mltbmy NEW RESIDENTIAL MEGI;. SQFf. y r011PI}IDO
lfy the Pa the requirements which rwatbemataCert rate o(O co a cy.
Owner or out orlu e t Date
TOTAL: I ISSUED 0Y: _
OFFICE COPY