23847 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 16070 l • p 23847 .
neve ams' one:�/ A
7 CITY OF CUPERTINO-BUILDING DIVISION
Cow ma: SAPPLICATION I PERMIT (p l
BUILDING-ELECTRICALML BING-MMMNICAL CATEGORY CONTROL N
Agch tect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �•
LICENSED CONTRunder rDECLARATION '-kms
I hereby n70 that lamsionxd uederprovlsln Profesapter9(mmmen MPLIANCESAEBIDENTIAL JOB DESCRIPTION
Ingwit ISI full7000)of Dl effect ofthc Buslnessand Pro(easlons Code,and my �
I
Is In fu8 fo and effect ��/.s�r PANELS APM-t+
Llanx Ch LIc N 7 �a/r I F
Dated Contractor
ARCHITECTS DECLARATION 201-1000AMPS
p�p�uu 9 Z I uade.t..d my plans shall W used as Public remrdL OVER I"AMPS pq /`�\I�.FLOOR AREA $/SQ.FT.
Fi �j Licensed Professional SIGNS ELECTRICAL M 'J !i 1 L'... LE L'✓
t�° OWNER-BUILDER DECLARATIONh `,{/I [r p�� !
ZH�4 Ihereby affirm that lamexemptfromtheContractorSPECIAL CIRCUIT/MISC Contractors 9J7 !A U T L `
follawing M reason.(Seaton 7m1.5,Buslnee.end Profs®Ions Code;Any ctty or j/
countywhlch rcqulreaa perMttoconstmct,alter,lmprove,demollsh,or repair TPMP.METER OR POLE!NST.
.a anystmcture prlorto its Exuance,also requirestheappbcanl forsuch permit to E
POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the J
3 m
ff° Contractor.Liceve Law(Chapter 9(mnuroncing wkh Semon 7000)of Divi-
SWIMMING POOL ELECTRICH OslDn3ofthe Buslnessand ProfewWmCode)orthathelsexmpttherefromand VALU
6 the basis for the alleged exemption. Any violation of Section ect15 by any OUTLETS-SWITCHES-FIXTURES
1
applicant fora the
subjmsthe applicantioa civil fpenaltySects dnot rtnrethan 1.
five hundred dollars Mae. NEWRESIDENTIALELECTR SQ.FT. S
TORIES TYPE CONSTRUCTION
1,as owner of the property,or my employees with wages as their sole
�246 mmpensatleetwildo the work,and thestruaure Is sot Intended or offered for ,
,F O vie(Sm.70K Business and Profmions Code:The Contractor's License Law
p'j3$ does nolapply to an owner of property who builds or improves themon,and I CC.CROUP AES.UNITS
whodoessuchwurkh4nselforthrough hisownemployees,provided thalsvch
Improvementsare not Intended orolfered torsade.If,however lhebuilding er
improvement ueald wlthinoncyearafcomplelbn,theowner-budderwlll have
telt,jiurdenotproving that hedid not build oNmpmve for purpose of sale.). QTY. ;PLUMBING PERMIT' FEE, ZONE APN
n L as owner of the property,am exclusively trading with licensed
renmactom to construct the project(Sec.7044,Businessand Professluns Code: PQLMTI ISSUANCE �►
The Contractor.License Law does nest apply to an owner of property who PETER-DRAIN&VENT•WATER(EAI
Wilds or Improves thereon,and who contram for such ptajem Wit,a
��B�[actor(s)licensed pursuant to the contractor's Lianx Law. FEE SUMMARY
LJ I am exempt under Se=.' B&P C for this mason BACK FLOW PROTECT.DEVICE
COwner a DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
T WORKMAN COMPENSATION DECLARATION FD('NRFS.PER IRM �� SCHOOL TAX Y 'N
of hereby.(firm that 1 have a certificate of consent t°self-Insure,ora REC NN
a cedl@ate D(Work &Compemationhuuranmoramrtlfledmpythemo!(Sm. CAS EA. INCA OUTLETS PARK• •
3800,Lela CJ M, Y_ N_
ComPoliry n GAS EA.SYSTEM-0VCR 4(FiY) RECEIrf p
Y BUILDING DIVISION Fr.I'S
edified copy Is heed with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cedified copy Is hereby ththe city Inspection division. '
CERTIFICATE OF ET(EM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANHARY-STORM EA.200FT. Date RCCeI LA
(Dissection need not be completed If the permit is forone hundred dollars
(8100)Dr1eaJ performancerti/ylhat In the performance of the..,it for which this permit le issued, WATERHEATERW/VENT/ELECENERGY FEE Y N
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAjD
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date RCCeI tq
Z Q NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor _ TOTAL:
Iq Code,you at fort hwlth comply with such provisions or this permit shall be G, .w
deemed revoked. FEE
LU
—a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherabyaffirmihattherc LsemnstactlDn lendingagenry(orthe perform ��, ELECTRIC FEE
M Z ance ofthe workforwhichthlspermit 1.bused&r.3097,Civ.C.)
U O Lender'.No PLUMBING FEE r—+
LL F Leadar.Address QTY. MECHANICAL PERMIT FEE CHANICAL FEE
O W lartifythat]havercad this application and Yalethattheabove iTornutlon ME
d
11 Inconel]agree to comply with all co
city and untymellnanrn.andelat.law. PERMIT ISSUANCE I �Y• FEES PAID:
>_ W relating to building construction,and hereby authorize representatives ofthla
I— m
Z city to enter upon the above- antlonInspection property for purposes. ALTERORADDTOMECH.mDate RIN
_ Me)agree to save,Ind enlfy an d keep harmless the City of Cu pert Ino - CCeI P
against 11 ab illtles,ja dg nls,costaande nxa whi hmay inanywa accrue AIR HANDLING UNIT(TO 10,000 GEM) SUBTOTAL:
against.d in sequena°f anting this pa
AIR HANDLING uIJR rovEA lO,OW CFM) CONSTRUCTION TAX
24`-
Signature Df Applicant/Contactor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfnum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI tp
material as defined by the Cu pam..Municipal Code,Chapter 9,12,sad the
Ilea lth and Safety Cod a Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT
Rill
MN.
ill the applicant or future building occupant use equipment ordevime VENTILATION FAN(SINGLE READ) G ISSUANCE DATE
4the
hich emit havrdous air contaminants as defined by the Bay Area Air uality Management District? BOILER-COMP C311POR 100,000 BTU)
—IYesg N°
I havereadthehaza o..materialsmquimm ntsunderChapter6.95of BOILER-COMP(OVIR 100,000 BTU)
California Health&SafetyCode,Sections 25505,25533 and 25534. Iwa� ,,
'understand that If the building does not currently have a tenant,that It is my NEWRESIDEbMALMECN. SQ.PT M or
responsibility ofaCanotify he occupant of the temOcupa.eyulremenla which must be met
r prior to Issuance oda Certi(Icate o(Occupanry. JL,�
Owner or authorized agent Date 1SSllE'�[5//4�I IL J
TOT L, H
' IYy
OFFICE COPY