22083 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PKRIAHNO.
Building Addreaa//.fc 0S � �j 22083 2083
weers ams. ora:
3O51F &V5P[L P4m .iii-S $(,(,-7o1y CITY OF CUPERTINO-BUILDING DIVIS16N
Cono-a;'a Name: - Lic.No: APPLICATION /PERMI awl
T L O.AJ 6M-0 41 'fa�7 BUILDING-ELECTRICALPL BINGM CAL CATEGORY CONTROL Q
Architect/Engineer, Lt
Llc.No: O
tis f�j c0' ER C-1112 Ll Qom. ELECTRIC FEE. ,BUILDING PER INFO
Addmsc /OG W.CAH,*As" PERMITISSUANCE J'E `e I�JT
LICENSED CONTRACTOR'S DECLARATION lC1
two
Ihereby affirm that l am Leensad under provisions of Chapter9(commen APPUANCESRESI E JOB DCSCRBef10N
Ing wlthSxcdon7000)of DWlslon3 olthe Buslneaaand PrefesslonsCode,and my
Ilanx le In full fo and d(ect. y PANEL S �� C'y1 ry,��-.yG
Llanx Clam-
Lie.Is 4D' 71 - ` ` - (y��
Dat e�L��Contractorl4/�'Sf.WP p'\vim l�\
60
ARCHITECT'S DECLARATION 701-1
q�q�uu0 lundeatand my plane shag be used upublic recoNe. SQ FT gJiEA I 5/9Q.FI.
6iU LicensedProfeastnnal S ECTRIC IJB!!#6mT� 6oa3Gt
<<�6 OWNER-BUILDER DECLARATION PETALCIRC c
Z � herebyafll mthatlam exemp (romthe Contra ors License Law fo th
Q following reason. 7031.5,Business and Profexlmns Code:Any city or �vYi
F1^ty county which requla.a permit tomnstmct,alter,Improve,demallsh,orespalr - P.METIR ORPOLE INST.
_ ❑ anystmmmpdortolrebsuance,aLorequimstheapp0antforsucbpermltto POWERDEVICES
m�
K 0.S file a signed statement that he L limned pursuant to the provisions of the
Ou
Contractor's License Law(Chapter9(commencing with Section 7000)ofDial.' SOS ston3ofthe Businessand Pnd.1o.Code)orthet he L exempttheafromand SWIx(MING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLF.TSSW[TCHESFIXTURES
f]
applicant fora permibubjects the applicant to a civil penalty of not more than
$ five hundred dollars($5(i0).
NEW RESIDENTIAL ELECTR SQ.FT.
❑I,as owner of the property,or my employees with wages as Their sole STORIES TYPE CONSTRUCTION
compensation,willdothework and ions Code:reh not intended orofferedfor
D dale(Sec apply to aniowand f property
Code:The Contactors License Law
does S$ whodic such apply teen imserafprough his o n ilds emporlmprovvided that
and OCC.GROUP RFS.UNITS
whodoem nts amwork himxlodoroughh6ownemplhow.providedtllding h
Improvements ithindedoroofco tarsals.l(h ner-buflderwilI have T ® !•
or
Improvement L sold within oneycar ofcompldla,lheowner-budderwlll have
tlA_kurden of proving that he did not build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEEELOODZAN)? APN
u L as owner of the property,am exclusively contracting with Ilmnsed PERMI7ISSUANCE
contractors to construct the propel,(See 7064,Basin.and Professions Code: �
The Contactors Limnm Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EAI
builds or Improves thereon,and who contram for such ptojects with a
15actor(s)licensed pursuant to the Contractor's LicenseLaw. BACKFLOW PROTECT,DEVICE FEE SUMMARY '
I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Dale RECEFT It
WORKetAN COMPENSATION DECLARATION pp(NREq ppg.l.RA1' as-a SCItODL TAX Y_ N_
F11 hereby affirm that I have•artNote of consent to xB-inmrc,ora RECEIPT 0
asof Wmrken'Compensatlon Wuranaora certilled copythenrof(Sec. GAS EA.SYSTEM-1 INCAOUTLEFS
3800,00,Lab
f C.) �' PARK FEE Y N_
I aliry M GAS EA.sYSI'EM-OVER 4(EA) RECEIPT M
Co❑pm any BUILDING DIVISION Ff:OS
certlfled copy L hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed copy L filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE ---6-ate
(TN.xction need not becompleted lfthepermlt Lforonehundred dollar. SEWER-SANITARY-STORM EA.700FT, Date Rett's PIN 7 O
Wall)or lex.) WATERI�TERW ENERGYFEE Y N
I mHilythat in the performance.!thawork fm ,vhlch this permit is Issued, /VENT/Q'ECTR
I shall not employ any person In any manner so u Tp b 1 sub'ect to the WATER SYSIPM/TREATING
Worlicant ons nation V ap�t -are a.Date 3
O Z NOT]Applicant n�/L` NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t#
Z Q NOT] be mne.ubAf'PLIGCNT: ,Worn ma CompLCettlllrao is Exemption,you
sods,yo =aeon fortject hwith
the Workers'Compewttons orthlons ofthe rmit&Labbe TOTAL:
W W dwered you=at forthwith comply with such provisions°`this permit shall be
> deemed revokes. BUILDING FEE
W G CONSTRUCTION LENDING AGENCY t SEISMIC FEE REV
CL Iherebyaf0rmthatthereLe construction lending agency lorthe perform 11
ELEGTRIG FEE
Z once ofthework(or which Isis perMtLLsued(Sec.3097,Civ.C.)
U O Lander'.Name PLUMBING FEE
IL F Le.der'.Addreas QTY.jA7LTTR0RADDTOMECH.
ANICAL PERMIT FEE MECIiANICALFEB
O W I artifythat l have read thisappllationand statethat theabove Info mnstlmn
Ismrrect.I agree to complywith all cityand county ordinance.and Yate laws CE �- FEES PAID:
} a relating tobullding construction,and hereby authorize representatives ofthis
F- N city to enter upon the above-martioned property for Inspection purposes,
? (We)agree to save,indemnify an d keep harmless the City of Cu proton Date Receipt#
V agaWtRabII les.judgename,mats and expenses which may in anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalnstu tyfi,cce quenaotthegm.tmgofthispennit -
AIRHANDLING UNIT(OVER lit"CrM) CONSTRUCTIONTAX
[SignareNmt Applicant/Contractor nDte EX11AU5'T HOOD(W/DllCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO URE f _
Will the applicant orhinere building occupant store or handle hazardous HFA TING UNIT(TO 100,000 BTU) ��'� Date Recei t
materials.defined by the Cupertino Munldpal Code,Chapter 9.17,and the
I iealth and Safety Code Section 75532(x)7 HEATING UNIT(OVER 100000 BTU) TOT
❑YeaNo
Willtheapplicenl or wmbuildingo pantumeq.1pment.rdevicas VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdms air contaminants as defined by the Bay Area Air Al
Quality Management Dstrict7 BOILER-COMP QHP OR 100,000 BTU) P M 1 R/
4 Yes 9 No
havereacithebaza mus mrterlals requirements under Chapter 6.95 of BOILE R-COMP(OVER 100,000 BTU)
the Canter i.HealthASafely Cod,Scrtioru7.ri505,ZW3and7:534.1 �",
understand that if the building docs not currently have a meant,that it is my NEW RESIDENTIAL MECH. Hi
SQ.FT
responsibility to notify the occupant of the requbermnts which must be met
prior tm L.uanceofa CertiRcate of Occupancy. tD,J yf)'IJ�
CIl��[Y
Owner or aulhorlud agent Date TOISSUED BY:T ..
— OFFICE COPY
_ t