23529 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Add as:
IOfQ AKLA23529
nen ane: one: APPLICAI
y KAMY shloAl CITY OF CUPERTINO-BUILDING DIVISION
cantrsnarswme: Lie.No: APPLICATION I PERMIT
BUILDINGS.ECTRICA-PLUMBINGMECHANICAL CATEGORY CONTROL 0
Architect/Fogtneer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcu PERMITISSUANCE 1� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION of Chapter
I_.FJ ,R�
Ihereby Sccfo 70thrtlamlkeneeduMerprovlsidprofehionsCommmrno APPLIANCESRESB3ENTIAL JOB- DFSC�ON
Inense 1 Section force and
effiaon3 ofthe Buelnessand ProfessionsCode,and my T ,�►'F��
license bin full force and Lie.If PANELS
LI Dafte Class Lk.Y
Date Contractoru`
ARCHITECTS DECLARATION - 201-1000 AMPS ral
I understand my plana shag be used as public records. OVER 1000 AMI'5 l FI(�) Fla II/SQ,FT.
Fe o Licensed Pe f sa m iii SIGNSELECTRICAL PAR U TERM
OWNER•BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Z ? Ihercbyalfirmtimison exempt from Contractor's License law for
pp following reason.(Section 70115,Business and Professions Code:Any city or
Fcmntywhich rcqulrcsa perMlbmrulruct,alter,Mpmve,demoWh,orrcpalr
OZi. TEMP.METER OR POLE INST. 114 E
E
any stmctum prior to its issuance,also requites the applicant for such permit to POWER DEVICES OJ6 �+
fib a signed statement that ha is licensed pursuantCV/
to the provbiota of the
3u' Contractor's License Law(Chapter 9(mmmentlngwith SM1on7000)ofDivi.
�Og sion 3 of the Busines,nd Pedeadmas Code)orthat he is exempt therchumaM SWa1'WNGIWLELECIR(C � � ��VA/LLUUA�ArTr�IION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES {iFlal7esr�
appllant fora permit subjects m
the applicant to a civil penalty of not ore than
five hundred dollars(SM. NEW RESIDENTIAL SLUM }7.
❑I,as owner of the property,or my employes with wages as their sok STORIES TYPE CONSTRUCTION
compesaalion,wi ldo the work,an ithe structure is not intended or offend for
Osle,(See 7064 Busiruss and Professions Cade:The Contractors License law
$ does not apply to an owner of property who Wild,or improves thereon,and OCC.GROUP RES.UMTS
who dmssucu work hlmself orthrough hie awn employees,provided that such
improvementsom not Intended oroffered for sale.If,however,thebullding or TOTAL:
Improvement bsold within oneyearofmmple io4theowner-builderwill have
tl�urden of proving that he did not build or Improve for purpose olsale.). QiY. PLUMBING PERMIT FEE FLOOD ZONE APN
u 4 ae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to canstmet the project(Sec.7044,Business and Professions Code; -
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
Wilds or Improves thereon, and who mntatls fm such plajem with a
ador(s)licensed pursuant the Contractors License Law. FEE SUMMARY
I am exempt under Sec. B 11k P C for this recon BACK FLOW PROTECT.DEWCE
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y �N
. Date RECEIPT p
a,q WORKMAN COMPENSATION DECLARATION FB(TURF_S PER TRAP SCITOOL TAX Y N
1�hereby affirm,that I have a mrtiBrate of...t to eelM1lnare,m a RECEFr M
rtD,L.b C.Worker'(Camper/wtironlns/unnamaartified mpythereof(Sec. GAS FASYSI•EMI INC.4OUDETS PARK FEE Y N
3800 Lab C.) all_'}app—`Y" _ _
Polity Y CAS EA.SYSTEMAVER 4 MA) BUILDING
M
Com ny BUILDING DI VISION FEES
Certified copy Is herebythcity Inspection division. EP
furnished.
Certified copy b(fled withththe city GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Reel t#
Rule section need not be completed If the permit b forone hundred dollars
(51°03 mIcaJ WATER HEATER W/VENT/E.[CTR ENERGYFEE Y N
I cetifythat In the Performance of Outwork forwhlch this permit le ba ted,
I shall not employ any person in any rta.no,m as to become subject to the WATER SYSTEM/TREATING s
Workers'Compensation Laws mf Call(omIla.Date AID
O Z Applicant NEW READPNITAL PLMB. SQ.FT. Date Recel tk
Z Q NOTICEco APPLICANT: after rs'Comakinpet atim press Exemption,you
should become subfctlto the Wrrkers'Compesatlon provisions ofthe Labor T TA
04 Code,you moat forthwith comply with such proislota orthis permit shall be _BUILDING FEE
deemed revoked. SO E
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I herebyaffirathat there is a construction leadingagenry forthe perform, ELECTRIC FEE
:3 Zanmofthe work forwhichthb permit Is issued(Ssc 3097,CIv.C3 TOTAL:
00 Ieader'sName PLUMBING FEE
LLF Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedifythat l havereadthb appliationand statethat theabovelnformation
1 bmrtect.l agree to comply with all city and munlyordlnances and stale laws PERMIT ISSUANCE FEES PAID:
>- relating to building construction,and hereby authorive representatives of this
W
I- 0 city to enter upon the aaovo-mtntWned property for Inspection purposes. ALTERORADDTOMECH.
— Me)agree to save,Indemnify an d keep harmless,the City of Cu portion Date Recti tN
against fiabillties,' dgmenb,costs and expense which may In any wayaccrue AIR HA NDLINC UNIT(To 10,000 CFM) SUBTOTAL;
agzl aid City mneeque.of the gratuing of this permit.
4-�ti'2Z� AIR HANDLING UNIT(OVER IO,DDOCFM) CONSTRUCTION TAX
Signatureo( ant/Con Tactor Data IXIIAUSTHOOD(W/DlX:7) CONSTRUCTION TAX Pe/'gIr-� B 6d
A2ARDOUS MATERIALS DISCLOSURE f/`•
Wlllth app cart orfuturc building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) ------VVV
material as defined by the Cupertino Municipal Cade,Chapter 9.1Z and the _ Date Reeel t#
I lealth and Safety Code Soclon 2553200? HEATING UNIT(OVER 100,000 BTU) TO
TT��Yea No
EMIT theepplicant Men building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) - I!PUANfVATE
which emit hazardous air mntareirenls as defined by the Bay Area Air IN AA U!
Quality Management District? BOILER-COMP QHP OR 100,IX0 BTU)
MYea No
have read the haze Q nus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,DDD BTU) APR Q 1�
pgg�
the California Health h Safety Code,Sections 25505,25513 and 25534.1
ucad erstacad that if the building does not mrrently have a tenant,that it is my NEW REST DENTAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which moat be trot CliY ser laUrtrlltlVU
prior to Issuance d a Certificate ofoccupe nry.
Owner or aul horbed agent Data ISSUED BY: LN
t.
TOTAL:
OFFICE COPY