23402 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building project Identification PERMITNO.
ewlam4AaareasC n 23402
w n one:
CITY OF CUPERTINO-BUILDING DIVISI
AdIlk cont ctor'eName: LIc.N. APPLICATION I PERMIT
�'u' 1, O4 X4'11/;/ BUILDINGELFCTRICAGPLUMBING- CATEGORY CO L /�
Arch11M/Engineer. Lic.N.
MECHAMCAL `S
—4929"JQTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 1 PERMITISSUANCE ❑ ❑
LIC ENS EDCONTR under DECLARATION
I hereby
ectionmthat l am licensed 9=3ofthe ugnemandprovidonsP ffnslmsr9de,and a APPLIANCESRESIDENTIAL _70B DESCRIPTION
inense1StHon form
died. o(the Butnessandlkofnslona Cade,and my tom'
loaners Is In full(Drax end effect. PANELS
Llcen Lk.p 1 tp 9
' e Contractor
ARCHITECPS DECLARATION 201-I000 AMPS
flp❑❑P++zr. I understand my plans shall be used as public recoa00
ds. OVER10AMP5 SQ.17.FLOOR AREA $/SQ.FT.
E F-. Licensed Prdesslovl SIGNS ELECTRICAL I N
dG a<� OR-BUILDER DECLARATION SPECIAL CII(CUT/MISC
g fQ-id a owing reason.asorm that I Sectimm 31.5,B si m a Com leado License law for the W T E R
O2— lollaywhichrequieata Nn ttom means Professions.mle h,ormpiny city r TpATp MEM OR POLE INSf. /
K� ceyt.d mregWros issuance,
requires the
a pmvgaemsuch,ermit tr 7
any stmture statement
hate is also sed pursuant t the for aionsch of It a POWER DEVICES r /
O lion o signed statement le at he b r licensed pursuant it the Pon 700D) of the
w� due3Contrftha License Law(Chapter9Ccle)mthd wilexemonherefof Died-
due
ivl- VALUATION C:10
E,�OS elon3o(lhe Rusinessand ProfcubvCode)orthat hehexempttherclromand SWIMMING R70L ELECTRIC - `N
y.' the basis for the alleged exemption. Any violation of Section 7031.5 by any
O< applicant fora permit subjects the applicant to a civil penalty of not more than OUTLET3SWIT'CIIESHXTU2ES
$ Aundyed dollars(SM. NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
5,L as ower of the property,or my employees with wages as their sole
k�6 compensation.wBldo the work and thestacture brat Intended or offered for
$ O
.1.05,,7064,Redeem and Professions Cade:The Contractors Lt..Law
docs not apply to an owner of property who builds or Improves t berron,and
a. who does suchwork himself orthrough els own employee,provided that such OCC.GROUP RES UNITS
Improveme t,4m ratintendedoroffered(ovate.ILhowevegthebullalogor T �t
Improvement bsold within oneyearolcample ioMtheowner-buBderwillhave
t)�vrden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD7ANE APN
�f I,sue owner ER
of the property,am exclusively contracting with licensed PMITISSUANCE
contractors to construct the project(Sec 7061,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who
builds or improves thereon, and who contracts for such p(o)em with a ALTER-DRAIN&VENT-WATER(EAU
cq14e0or(s)licensed pursuant to the Contractors Lictow Law. . FEE SUMMARY
' LJ I am exempt under Sec. B&P C for this much BACK FLOW PROTECTDEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIVE M
WORKMAN COMPENSATION DECLARATION p0(IURF_S PER TRAP SCHOOLTAX Y N
QI hereby affirm that I have•certificate of convent to self-Imam,ora RFGE07 N
ceM1lflateof Workems'Compens.Boni.uranaonartifledmpythereof(Eec. GAS G.SYbTEM- I :'[( y N
3800,Leb C.)
Ibliry p — RECE87 M
Com an CAS EA.SYSTEM FR )
Y BUILDING DI VISION FEES
Cenlfied copy b heed with the
city GREASE/INDUSIA W S I HE �s
� ed
CertUed mpyb(iled with the city inspection division.
CERTIFICATEOFOtEMPTION FROM WORKERS' GREASE TRAP PAI V
COMPENSATION INSURANCE SEWER-SANITARY-BTO ate
(Thismtlon need net becomptted if the permit bloc one hundred dollars
($100)aless.) ENERGY FEE Y N
Icertifythat in the padmenance of the work forwhich this permit is band, WATERHFATERW/VENT/ELECTR
1 shall not employ any person to any manner an as to become abject to the WATER SYSTEM/TREATING
Worken'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. Date RCccl t#
'.Z Q NOTICE TO APPLICANT:ILaNer making this Certificate of Exemption,you gQ'Fr•
f" should becomesubjcd to the Worken'Compematton provisions.!the Labor TOTAj'
N Code,you most forthwith comply with such proWions orlhh permit shall be
> durred revoked. BUILDING FEE
LUg CONSTRUCTION LENDING AGENCY SEISMIC FEE X
Z IheicbyafBrmthat there b a conduction lending agency for the perform.
TOTAL: ELECTRIC FEE
anca of the work for which this permit h imend TS 3097,Civ,CJ
V O Lemderi N.me PLUMBING FEE
IL H Lemdera Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iunlfy that I have read this application and elate that the above Information
6 Isroretu
.I agreetocomplywithallcityand comtyordlmamcesand state laws PF"tTISSUANCE FEES PAID:
W relating tohulding construction,and hemhyauthortmmpremntativiceofthi.
I— Z city to enter upon the above-mentlomed property for Inspection purposes. ALTER OR ADDTOMECH. DBIe RCCCI f#
z (We)agree to save,ind merufy an d keep harmless the the City of Cu perttno
against lbblltnes,judgments,cots and expenses which may In any wayaccrue AIR HANDLING UNIT(TO 10,030 CEM) SUBTOTAL'
aga inst mid City in mvcquena of the RranHn mal.
Tom('=(/, S- AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
Signa of AppEant/Contractor Data IXHADSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wtllthcapphantorfuture building occupant Store or handle hazardous HEATING UNIT(TO 100,000 BTU)
maten.1maefined by the Cupertino Municipal Code,Chapter 9.1$and the _ Date ROCCI t#
I hv1fh and Safety Code Su lora 25532(.)7 I(EATING UNIT(OVER 108000 BTU TOT t.
RYen �j No
ill the applicant wfuture bu old Ing occupant use equ 1pmnnl or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
hlch emit hazardous air contamiinanb as defined by the gay Area Air
duality Management Dlstrit7 BOILER.COMP(3HPOR 100,0W BTU Li B D
'�I, I Yn 9No 1'Y
Thaveria ealthhe a ausmtenab rtioW25505, SS33under
and 2S5r6.9i of BOILER-COMP(OVER IN,IX108N)
theersta dt Health&Safety Code,semonsntly h ve a tennd255a4.tit DIY q
understand that If thenose building dont not erequiru nest which
that b mot NEW RESIDENTIAL MECH. SQ.FT. 1Y d qnn?
reser to issuance
of aCeheocate of Oct panty.lremenb which mut be met C 1a7a7®
prior to lteuance of a Certificate of Occvpanry. V 1 1 Y Ur CUYt
ryll U
Owner or aulhorlecd agent Date ISSUED RY:�
TOTAL:
OFFICE COPY