24206 ARPAICANTTO FILL IN INFORMATION.WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro ed Identification PIIIMIT N(], O
Building Address: Z
002 � lMD C �`T CL/ ea-rin n qScI
wners ante: n one: - A
Ih
S 1 �l O ANO 7' �n�I I CITY OF CUPERTINO-BUILDING DIVISION
Co .cor° came: Lt..No: APPLICATION I PERMIT
r L'L7eJ 6� BMLDINC•ELIDCTRICALPLUMBING. CATEGORY CONTROL M Archlted/Engineer. Lle-No: MPGFIAMCAL.
QTY .ELECTRIC PERMIT, 'FEE BUILDING PERMIT INFO '
Address: `- PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION LFI'
]hereby aM.that l am licensed under provide..of Chapter9(mmmen APPLIANCES-RESIDENTIAL ]fig DFSCRB'TION
Ingwlth Sadion7000)ofDiA.i.3ofthe Businessand Profeadon.Code,andm -
limoseislnfull and affect.. PANRLS 'a
Llcen.0 m Lich
Dale ��Contractor 6/LL S K L�}1�/�r1
CHITECTS DECLARATION I)� 201I(DOAMPS �•` , "
aOQ= I understand my plans shall be used aspubllcrerorda OVER 1000 AMPS SQ.Ff.FLOOR AREA 3/SQ.FT.
t' Licensed Professional SIGNSELECTRICAL .
uu�ll OWNER-BUILDER DECLARATION SPECULCRiCU1T/MISC -
Zt., �a Iharcbyafflrm that]cam exemptfmmthe Contractors Licence Lawforthe
OO
Ofollowing reason.(Section 7031,5,Business and Profession. y ty orCode:An tl zj.�
F, -
� county requlresap¢rmitrocoamd
t ,aller,ImprovG demolish,orreTEMP.METPR OR POLE INST.
palr _
QQgg any structure Prior to ib iuuanee,also requires the applicant for such permit to .t
file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Ow Contractor's License Law(Chapter 9(romvruncing with Scalen7000)ofDial.
30r^ 1..3 aflhe Busineuand Profeulov Codeorthalhelsemmptiherefromand SWIMMING POOL ELECTRIC VALUAR91`6
s. yd'g the basis for the alleged exemption. Any violation of Section 70315 by any Ir��/ CJ��
<.e
applicant fora mit sub' thea Bcantma civil 1 ofnot moretlom OUTLETSSWITCFIFSH%'1'URES L 1;
PP Per lis PP Pena ty o(,
Iroa�hundred dollars(5500).
N NEW RESIDENTIAL ELECTR
W 1,as owner of the property,or my employees with wages as lhU esok �'�'' SfO10FB TYPE CONS RUCTION
mpenutton,wOldothe work andthe stm=m b not interceder offered for
q uie(Sec.7064,BuelneasarW Pmfeslons Code:The Contradors Llame Law
�$ does not apply to an owner of property who builds or improves thereon,and
EEE who does such work hirmalf or through his own employees,provided that such OCC.CROUI' RES UNITS
Improvements are not intended oroffered!anile.If,however,thebuilding or TOTAL:
Improvement bsold within one ysarof complMlon,the owner-budderwill have
Ol,L�uden of proving that he did tout build or Improve for purpose of sale.). Q7y, PLUMBING PERMIT FEE F[.00p TONE APN
Lj I,as owner of the property,am exclusively contracting with licensed pp,((MIT IBSUANC&
contractors to construct the muted ns(Sec.7044,Business and ProfessioCode:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAINk VENT-WATER(IA) _
Wild°or improves thereon,and who contracts for such pW*u with a -
Tyldenial licensed pursuant to the Contractors Llanse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY'
am exempt under&a B k P C for this reason
OwnerDRAINS FLOOR ROOF, SANITARY Y N_
Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FDCNRES.PER TRAP SCHOOL TAX Y_ N
sF-'III hereby affirm that I have a rertl0ate of consent to ulf-Insure,ora RE.CErp r a
](late of Worken'Campawtionlnsunnceora cedifkd mpythemof pec. GAS EA.SYSTEM.1 INCAOUTLEIS
3800,lois CJ PARK FEE Y N
PaucyN IA/r A / 122¢5" —O Z, DING IV
Com CAS EA. -
Y BUILDING DI VISION FEES
4Clmlfled copy is�erebyth the
CRFASR/1NOUSTRL WASTE INTERCEPTOR PLANCHECICFEE
Cil Cetlifled copy b(Bed with the d!y Iropectlon divlelon.
i*'` CERTIFICATE OF EXEMPTION FROM WORKERS' GRRASETRAP PAID
COMPENSATION INSURANCE SEWER4SANITARY-STORM EA.200F1'. Date I Recd t61
(f)orsection need notbe completed if the permit la(Drone hundred tlollan
(8100)sfy that
WATER HFATER W/VENT/ELFCTR ENERGY FEE Y - N
]certify employ
the person I any of he manner
an as t bthfe permit ct to the —
I shall not employ any person In any manner n m to become subject to the WATIN SYSTGM/TREATING
Workcn'Compenution laws of California.Date PAID - •
Z Z Applicant Date Remi Iq
_Z Q NOTICETO APPLICANT.If,after makingthis Certiflateof Exemption,you NEW RESIDENTIAL PLMB. �Ff.
should became subject to the Workers'Compensation Provisions of the Labor - TOTAL:
~ N Code,You most forthwithcomply with such peavlalms mthis permltshall be B IN �••
j deemed revoked.
a 'CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there h a construction lending agency for the perfortry TOTAL: ELECTRIC FEE
Z once ofthe work for which this permit is issued Ogre.3097,Civ.G.)
U,O lander.Name PLUMBING FEE
LL H . Landar.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE '
O W, I certify that l havereadthisappllationand elate thallheabove information
iscomed.I agree to comply with all city and county ordleances and elate laws PF"ITISSUANCE FEES PAID:
>. C relating to Wilding construction,and hereby awhodze representatives o(thb - -
H N city to enter upon the ahovcmentionad propertyforiespedion purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receiptit
V against liabilities,judgment,contused expenses which may In anywayamrm AIRHANDUNG UMT(TOtO,OWCFM) SUBTOTAL:
againstuld City inonaequ�fthegramingothb1t. _
iAL/Vet AIR HANDLING UMT'(OVER IO,000CFM) CONSTRUCTION TAX
Slgwtumof Appant/Contracts. Date EXHAUS'TI100D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or town,building occupant store or handle hazardous HFATING UNIT(TO 100,000 BTU) Date RCCeI tf7
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL
Yes I`I No _
Will the applicant s lure building occupant use equipment or,device. VENILATION FAN(SINGLE RESID) ISSUANCE DATE
whichemli haaardess sucne odearms.defined bythe Bay Area At, ..
. Quality Management Diririd7 BOILER-COMP OHP OR 100,000 BTU) -
4Yes ❑No
haveread the h , male lalsrequimmentsunderChapter6.95of BOILER-COMP(OVERIW,000 BTU) yy
the
Califamia Health de Safety Code,Sections 25505,25S33 and 25536.1 W
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which must be met SES •p
priortotssuana ofa CedifiateofOceupancy. `T 1 ✓,` �� e
Owner.,auihodzed agent Data CII Y VT sal
V
TOTAL: ISSUEDBY:
OFFICE COPY
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