20784 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed Identification PEAhlHNO.
Building Address: n
S- O O
S f{vim C��� G o 4
�Ovoslii ame: one: p
alf CITY OF CUPERTINO-BUILDING DIVISION �7 n
conba o< , 1^� LIc. e: APPLICATION /PERMIT ! —2'�—`(
L)4Nt -A XY C— CATEGORY-CLECT[tICA4PLUMBINC-MUHAMCAL CATEGORY CONTROL X
Arc ltect/ neer. Lic.No:
QTY ELECTRIC PERMIT PEG BUILDING PERMIT INFO
Addrne: pLItMIT ISSUANCE [:] [:] S 1:1LICENSED CONTRACTOR'S DECLARATION YIJO
Ihereby
affirm
on700that l Division
licensed oftheBrp essandomestonen9(commrnc APPDANCESRESIDENTAL JOB DFSCRIPHDN
ficen h [Ofan7f100)o(d effeon3o(1he Butlneeeandpm(essioneCode,and my
L U Ie=n hu nd c.# SI PANELS u Q
License Chs.' Conti D �— seal
Date Contractor —UP TO 200 AWS
CHITEC'SDE ATION 701-IMO AMP,
1Q+�QCO Iunders d res as s. OVERIOOOAMPS e SQ.FT.FLOOR AREA $/SQ.FT.
E (/ 145.1rdelaraessi.nal SIGNS ELECTRICAL
6 -OWNER-BUILDER DECLARATION
rn SPECIAL
t., Iherebyalfirmthatlem exempt(romthe Contractorb License Law for the CIRCUIT/MI
�� � , (olbwing reason.(Scnlun 70315,Balnese and Profevlone Code:Any city or TFMP.MEfFRORPOLESCINST.
countywhich requbna permit rommwct,alter,Improve,demolish,ormpair
'a'`'a CI anystructure prior to its Issuance,aheorequlresthe applicant forsueh permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Dial- SW24MINC]OOL ELE C
SOS Slo03 of(he Business and Professlon,Cods)mthal he is exempt themfromand VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLEISSWICHI&
appllantforapemdtsubjects(heapplicanttnadullparityofnal.n than
five hundred dollars(x500). NEW RESIDENTIAL ELECT
TORIES TYPECONSTRCTION
�n ❑I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure b not intended or offered for
M sale(Sec 7044,Business and Promshms Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and CC.CROUP RES.UNITS
E: whodoessuchworkhimselforthrough hlsownemployms,provided that such
improvements are nm Intended oroffemd forsale.IL however thebuilding or
Improvement Lsmid within omyearofcompldiogthe owner-bullderwlll hsve
tFeJ,vrden o(pmving that he did not build or improve for purpose of
'..'less QTy; PL $ LOOD ZONE APN
Lf I,as owner of the property,am exclusively contracting with licensed
contractors to construct the projed(Sec.7044,Business and Professions Code: PERMIT ISSUAN E [1(m
The Cont adore License Law don not apply to an owner of property who ALTER-DRAIN k -WATER(EA)
Wilds or improves thereon,and who contracts for such ple ts ojwith a
yS(+ BACK FLOW PROTECT.DEVICE exu(s)llcensed pursuant to the Contractor's License Law. FEE SUMMARY
I I am exempt under Sec. B Is P C for this rcawn
Owner Dale DRAINS FLOOR ROOF,AREA,GOND. 8tco SANITARY Y N_
- RECEIPT
WORKMAN COMPENSATION DECLARATION FIX�q,MR TRAP I.t't SCHOOL TAX Y N
❑l hereby affirm that I have o cunifiate of consent to spytheum,ora RECEIPT X
3801,abo(Workera'Compensatlonlnsuanceora artl(led mpythemof(Sec. CAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3olicyN CJ
Policy p GAS EA.SYSTEM-OVER 4(EA) RECEIPT X
Com any BUILDING DIVISION FEES
Certlfled copy is hereby tcid. CREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
F-lCertifind mpybfiled withh the the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' - CRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA.7BBFT. Date ROCCI t#
Rhor session need nor be completed if the permit b(orone hundred dollars
(810 nifytsdN
Imrtifyt - WATER HEATER W/VENT'/ELECTR ENERGY FEE Y N
hat the rm
oenceofthe work for which this permit) issued,
Ishall not employ an in any nunnepso as become sub'ct�o the WATER SYSTEhf/TREATING
WorIume Compens n Pea of CaljWrsl;l�Oate PAID
0 Z Appllant (/1/ NEWRESIDENTIALPLMB. SQ.IT. Date Recel f#
Z O NOTICE T- I ICANT:If,after na dng lids Zertlft of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shat l he BUILDING
LU > deemed invoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihercbya(fi—that there is a construction lending agency for the perform- ELECTRIC FEE
ZanreeftheworkforwhichthbpermltbL.sud(Sec.3097,C1v.C.) TOTAL:
U O Lenders Name PLUMBING FEE
LL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icenllythatl have mad this appilatlonand gate that the aboveinformanon
D. ISCOmed.l dgneeto complywith all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relatlngtob.ildingmmlmdi.,andherebyauthatl empmtalivesoflhis
I— Z city to enter upon the above-mentioned property for Wpoul's purpose.. ALTER OR ADD TO MFCH. Date ReCel f#
_ (We)agree to save,Ind emrdty,an d keep harmleas the City of Cu Fenton P
against liabilities,pdgments,cab and expenses which may In any way acerm AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
aga Wt said City In consequence of the granting of this permit.
' AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sigrutu re of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orluture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cod a Section 25537(a)? HEATING UNIT(OVER 100,000 IHU) TOTAL: hti+
Yes No 1
Wllltheapplianlor turcbuildingacvpaniusnequipmentordevices VENTILATION FAN(SINGLE RESID) ISSUA jy�E
which emR hazardous air contaminants as defined by the-Bay Area Air d
a lily Management D❑istrict? BOILER-COMP OHP OR IOgIXU BTU)
4 Yes 7 No
have read the hazy is materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sections 25505,25S33 and 25534. I
undetsbnd that ithe building does not currently have atenant,that It is my NEW RESIDENTIAL MECH. SQ.rr �(�nf Cll
responsibility, ell he occupant of the mquiremenls which must be met BBmnn p
prior to Lssu a nificate of0 an
n auihonved agent ^Date` O
TOTAL ISSUED BY:
OFFICE COPY