20465- APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMTTN'O.
Bu11�gAddresD p n�,EK7 �r I ANN 20465
n am. A
�vD612 TiND KC'm Of tqc- — CITY OF CUPERTINO-BUILDING DIVISION Z�
FdVntrasi.-t5or'sName: Lie.No: APPLICATION I PERMIT
_
c Q W I;r> O BIHLDING-ELECTRICALML BING-MECHAMCAL CATEGORY CONTROL X
Architect/Engineer: Lie.No:
QTY ELECTRIC PERMIT PPB BUILDING PERMIT INFO
Addross: PERMITISSUANCE ���J(/�'
LICENSED CONTRACTOR'S DECLARATION yam\ El
I hereby affirm that l am licensed under provisions of Chapter 9(comment APPMANCESRESIDENTIAL JOB DESCRIT'1'ION
Ingwith Sedion7D(D)of Dlvislon3ofthe Businessand PmfesslonsCod and my
license Is In full force and effect. ¢G PA IES 1
Licen.ClessC— LIC#
Data 2 g-qct Convattor Mum ala 201-l"AMPS
ARCHITECTSDE fARATION UP TO 200 AMPS
OVER1000AMPS SQ.PT.FL EA f/SQ.FT.
9z i understand my plans shall be used a public records.
CO
zd t, Licensed Professkmal SIGNS ELECTRICAL
�6FS OWNER-BUILDER DECLARATION SPECIALCRCUIT/M
Z f-�:/ I herebyaffiren that lamcxempt from the C rtractora License Law for the
following reason.(Section 70115,Business and Professions Code:Any city or
O� e- ter, TEMP.METER OR POL I
<�,� cwntywhkh requlroa Issuance,
AgK anymmctvrc priorto Its Issuance,aisorequlresthe applicant forsuch permit to POWERDEVTCES
K.
E6 file a signed statement that he is licensed pursuant to the provisions of the
�+13 u•�A Contractors License law(Chapter9(commencing with Section 7000)of Divi- NG POOL VALUATION
O alon 3 of the Business and Professions Code)orthat he b esem therefrom and
5 the basis for the alleged exemption. Any violation of Stolon 70315 by any O SWITC
applicant fora permit subjects the applicant to a dvil penalty of not more than
a live hundred dollars(SSDO). NEW R ENTIAL 7n,
❑I,as owner of the employees with wagesas their sole �'�' STORIES TYPE CONSTRUCTION
property,or my emp mye
;,: compensation CSM sun,Busmess and rk,Pr andthestmmurche Coal
Law
$�❑ sale(see 7014,Businn. and Pm(esslons Code:The CoNratloh Llcesue Law
�j$$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
whodoessuchworkhterselforthrough hisoweemployees,provided that such
Improvements are not Intended unaltered for sale.If,however thebuilding or TOTAL:
improvement issold within one year ofcompletlon,the owner-builderwlll have
th,0kurdeo of proving that he did not build or Improve for purpose of sok.). QTY. C±IP413ING PERMIT FEE FLOOD WNE APN
Li L as owner of the property,am exclusively contracting with licensed PERMHISSUANCE
contractors to construct the project(Sec.7004,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EAI
bWilds or Improves thereon, and who contracts for such placi
mjes with a FEE SUMMARY
,,RIdST(acourts)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LJ I am esept under Sec B k P C for this reasonOUTSIDE FEES
DRAINS-F R,ROOF,ARECOND. SANITARY Y_ N_
Avner Date A, RECEIPT'a
WORKMAN CONPFNSATION DECLARATIONHX'NRFS PER[RAI' SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-Insure,or• ff
RECEIPT N
certificateof Worken'Compensatlon Insurance oracertifled copy thereof(Sec. GAS FA,SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
3800,loisb CJ RECEIPT N
Conry S M GAFA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
Certified copy is hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ISO Certified copy m filed with the city inspection division.
Y' CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STOAM EA.200FT. Dale RCt1'1 tic
(Thissection need nM be completed lithe permit Isfor onshundred dollars
($100)orless.) WATER HFATERW/VENT/ELFCTR ENERGY FEE Y_ N_
I etrify Nat In the performanceof the work forwhich this pemdt isissued,
I shall not employ any person In any manner so a to become subject to the WATTR SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
0Z Applicant NEW RESIDENTIAL PLMB. SQ.Ff. Date RCcei tN
Z O NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
should become subject to the Workers''Compensation provisions of the Labor TOTAL:
W Cade,you=at forthwith comply with such provisions or this permit shall be BUILDING jr j tleemed moked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. I hereby affirm that there is a construction lending agency for the perforrtrTOTAL:vv
ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.Q PLUMBING FEE 2
V 0 lender's Name
LL F Lenders Address i✓Lc'-_ QTY. MECHANICAL PERMIT MECHANICAL FEE
OW Icekifytha l haveread this application and statethatthe above information
4 bcormet.I agree to comply with all city and county ordinances and state laws PFRMITIS5UANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
Zcity to enter upon the above-mentioned property for inspection purpose. ALTER OR ADD TO MUCH. Date Receipt#
(We)agree to save,indemnify an d keep harrdew the City of Cu Fortino AJft HANDLING UNIT(TO 10,000 CFM)
V against liabilities,jtdgments,costs and expenxe which may In anyway accrue SUBTOTAL:
against said g,ty n ence ofthegrantin permit.
� iCiIC.0-O� 9—z&^Ins AIR HANDLING UNH(OVER 1f1.000CrM) CONSTRUCTION TAX
Sigoamreof Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,0DO BTU) Data Recei tic
material as dented by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Cod,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: rW
❑ Ye L61 NO T
Willtheapplicant or lfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUA DATE
which emit hamrdous air contaminants as defined by the Bay Arca Air p�L 7,
Illy Ma nagement District? BOILER-COMP OHP OR 10000 BTU) O. d
Ycs ®No
above read the M1avNous rtutekab requirements under Chapter 6.95 of BOILER-COMP(OVER 100,00)BTU) S"
the California Health k Safety Code,Sections 25505,25533 and MM. I p��`aas�}A3,s/t
understand that lithe building does not comently have a tenant,that it is my NEWRF51DENTIALMECH. SQ.FT. P�
responsibility to notify the occupant of the requirements which must be mot
priorto Lssuencc of <k ate of=
Owner or auth agent Data ISSUED BY:
TOTAL: �
OFFICE COPY