21512 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Prn'ectAdemifkationPERMIT NO.
Building Add.,.:
zR
P N� r ro-p g _3 I 21512
r. /72r T �e CITY OF CUPERTINO-BUILDING DIVISION
Contractor'¢Name: Ic. APPLICATION /PERMIT
BUILDINGELECTRICAI PLUMBING-MFCHAMCAL CATEGORY CONTROL a
Architect/Englomr. Lir.No:
Qry ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreen: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(cco.c- APPLIANCESRESIDENTIAL JOB DFSCRIP730N
Ingwith5ectlan700)of DlWalon3otthe BuJnesandP fe¢(Arae Code,Andm
Ilmvc 1,In toll o daffect / C� { (((///p PANFIS
Data Cont 5 �00 7 /// v " ` � rte_ r�
Data Contractor r—Yl�Y°�R.'Yl/J
ARCHITECTS CLARATION 701-100 AMPS
NZ I understand my plans shall be used s public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT,
O
ob Li...d Professlooal SIGNS ELECTRICAL -
w OWNER-BUILDER DECLARATION
Ci] SPECIAL CIRCUIT/MISC
7 vl I herebyafRrm tial lame xempt from the Contractors License Law for the
following reason.(Section 7 131.5,Business and Profesione Cod n ct or
.O H y ty TEMP.METER OR POLE INST.
F�
countywhich requires pemNtmmostmct,alter,lm prove,de lish,orrcpalr
q anyetmcWrcprbrla lis issuanceaisorequlreetheeppllant such perMtlo POWER DEVICES
E5 file a signed&atement that M b Ilaenecd pursuant to the mWlos of the
3u, Conlnctore License Law(Chaper9(mmnnndng with Ionso fru(Dlv4 VALUATION
g�Os aon3oflhe Buslnesand ErafesbruCode)arMat he ..Pttherefmmand �'V'ENC IYJO ELECTRIC / ��Q e
Qthe basis for the alleged exempt on. Any violate f Section 701S by any O TS HFSFIXTURES ,
f� appBrant(ora perMleubjeets lheapplkanuoa Il pevltyof nal more thin
five hundred dollars(SM.
�n ❑Lasowneroftheproperly,ormye loyces with wages as their sok NEW D LTIR SQFT STORIES TYPE CONSTRUCTION
rompensation,will do the work and the duos is not Intended or offered for
O ale(Sec.7061,Buelrtes an,Profesl Code:TM ContractoYs Wttose law
S$ does nm apply to an owner of pro rty who W Ilds or Improves thereon,and OCC.GROUP RFS.UNITS
who dossuchwork Nmselfort gh hkownemployees,provided thatsuch
Improvement,are not lnlende orofferedforsle.lf,howevegthebulldingor TOTAL:
impommmentbsoldwithln yearofcompletlon,theowner-Wilderwill have
tll-purdenofpmvingth did rot Wild or Improve for purpose ofsaleJ. PL BING PERMIT FEE pEOODZONE APN
Lj 1,ae owner of tis property,em excluelvely contracting with Ilttnxd ANCE
contractors to roost the project(Sec 7614,Business and Prolesbos Code:
The Contractor's LI nae law dm nal apply to an owner o/property who ALTER-DRAW k A (EA)
Wilde or Impmw thereon,and who contracts for each pta)ectA with a
��B1l�acror(s)it. sed purivant to the Contractor'.Lkens Law. AIX PLOW PROT DEVICE FEE SUMMARY
LJ I am exempt under Sec B h P C for this reason
DRAINS $ F,ARRA,COND. SANITARY Y N
• OUTSIDEFEES
Owner Date RECER'IM
WORK MAN COMPENSATION DECLARATION FO(TIIRES SCI100L TAX Y
EiK ce _ N_
lam,hereby affirm that I have a rtlficam nte of consent to eel(-Ineurc,or RSCEB'T N
certifiate o(Worken'Compenutlanlosuranttora ttnl( ropy thereof 6ec. GAS�. -1 WC.40171LET5 PARK FEE Y N
3800,Lab C.)
Policy# T GAS EA.SY -OVER RECEIPTM
Com any BUI LDING DI VI SION FEES
Certified M&'is he furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�a/IRed mpyis(1 with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FT. Date Remi tg
(Thmneed rad be completed lithe permit is(arom hundred dollars _
p10)orlesla..)) WATER BEATER W/VENT/ELECTR ENERGYFEE Y N
Icenotrtify that in the person
of thework An"tforwhbech this ome subject
lsothe
I ehaB not employ any perwn In any manner w s to become mbJect to the
Warken'Compenstion Laws of GlifornisWATER SYSTEM/TREATING
. Date PAID
—
Z Z Applicant NEW RESIDENTIAL PLMB.__SQFT. Date Recei tN
Z 0 NOTICE TO APPLICANT.If,after nuking t his Certificate of Exemption,you
should became subject to the Workers'Compensation Emulsions ofthe Labor TOTAL:
N Code,youTorstfmthwlthmmplywithsuchpmvLl.roorthWNe tahallbe BUILDING
IL > deemed revoked. FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Iherebyafilrm that there b a roostmctlon landing agency for the perform- ELECTRIC FEE
Z ance of the workfor which this permit is issued(See C.)3097,Civ. TOTAL:
U O Lenders NamePLUMBING FEE
LLt- LandereAddra., QTY, MECHANICAL PERMIT FEE MECHAMCAL FEE
O IU 1unifythat l have read this applicetionand atatethat theabove information
Is COMM l agreelo comply withal]city and county ordinances And nate laws PERMIT ISSUANCE FEES PAID:
>. IL relating to Wilding construction,end hereby authorlaempreecntetiveea(this
(— z city to enteruponthe abovcmentlomd property for Inspection purpoaas. ALTERORADDTOMECTL Date Reeel 1n,
_ (We)Agree to save,Indemnify and keep hared City of Cupertino P
ag.moHUabll d s' Ten , ns Antl exp see whl yl ywayacaue AIR HANDLING TWIT(TO 10,00 CFM) SUBTOTAL:
Ag iyq(q a e o`he In of 1 1t.
AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTION TAX
S w of tt amen D te^ FXIIAUSTIIOOD(W/DUC'D CONST TAX PAID:
HAZARD LOSURE
Will the appllmntorfuNrebull o tetore or handle hazardous HEATING UNIT(TO 100,000 TIED) Date R6ce1 tR
material as defined by the Cup rtln u (Code,Ch apter9.lZandthe
Healt Pe
nTN nd Safety CodeLSep16o Z5537G HEATING UNIT(OVER 100,00 BTU) 9 'J:40TAL: L
Tu N
illtheappllontor uture building occupant use equipment or devices VEMITIATION FAN(SINGLERESID) U CE DATE
which emit hazardous air contaminants as dented by the Bay Area Air �dtry�yf��R'� ftp
Qali nagement Disfrt BOILFR-COMPOIIPOR 10,OW BTU) a+�+a7i("�'�l(rJ
o ( - 999
have read the haza Jaw, Lommalerlats requirements underChapter6.95 of ROIL[R-COMP(OVIR 10,00 BTU)
the California Health&Safety Code,SMloru 550.5,7553]and 75531.I
understand thatlithe the occupant note requirements
tenangthat it lsmy NL•WftENDENTIAL MIiLTi. SQ.Ff.
responsibility to notify the occupant of the requimmenle which must be nut
pdort uance ofa Cc scat o!O panty. µJ yp
or authorised agent, r Win ISSUEDBY:
.CrTOTAL:
OFFICE COPY