19908 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Pro act Identification PERMIT NO.
Building Address: I8
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(�
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nor ane/: Phone:
CITY OF CUPERTINO-BUILDING DIVISION
'• c° °or amc (� Lie.No: APPLICATION / PERMIT - g6
`ate BUHAINGD.ECTRICALnUMBINC-MECHAMCAL CATEGORY CONTROL
Architect/EngineerLic:No:
P :ELECTRIC PERMIT �){t`t� ,'1tFEEt ' ::I(HUIGDING,PERMIT'INFO '
Address: ' PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION . •'
I hereby affirmthat l am licensed under provisions of Chapter9(commose- APPLIANCFSRESIDENTIAL ]OB DESCRIPTION
Ing with Se 27000)o(Dlvislon3otthegualvssand ProfeeslonsCode,and my
licenseisln f don";ect � t PANELS /s�/M�� Ae
a<,
Llcen Lie:X /IJ (///
Dat Contractor '
ARCHITECPS DECLARATION 0AMI'S
97� Iunderetand my plane shall be used as public records '' OVER OVERI10(10 AMPS SQ.IT.ILCX7R AREA '$/SQ,Ff.
k0Licensed Professional - SIGNS ELECTRICAL
� < OWNER-BUILDER DECLARATION SPECIALCIR T/MISC
Iherebya(fimethet l am exempt fromthe Contractors License Law for the
OQQ "� following recon.(Section 7011.5,Businem and Professions Code;Any city or
m F TEMP.METLR POLE IM.
county mere rcqulrna exuarc,co orequi es the
a pmvq demolish,or ir
to
Cri any atructure prior statement
Lhat he e,aBensed cersuant applicant rovisl re,ofpermit e PO
(� file a signed statement that he B r9(curd pursuant it the tion 7")
na of the v _
3w
Contractor's License law rofesser9(commentlat he la xempttheW)om and
H�Ot the basft for
the alleged
Professions AnyCode °dation B exempt therefrom and SWIdMIN ELECTRI VALUATION�U
O the dab for the alleged exemption. Any violation civil
of na lty net m by any OUTLE TC YfLR �2�-X�
fiveapplicant delta. $SM.tstheappbcant Moa tivil penalty°(not morethan 'q Q /4V
flue Nuns owner
the W). SQ,FG bTpl(Ifvc TYIti CONSTRUCTION
1,as owner of the property,or my employees with wages as their sole D LEL TR
compensation,will do the work and the structure is not intended or offend for
O n sale(Sec.7014,Business and Professlov Code:The Contractor's License law
don not apply to an owner ofprop"who builds orlmpinvesthereon.and OCC.GROUTs RIS.UNITS
C: who donsuchw°rk hinesaforthr°ugh hlsownemployen,provided that such, kiv
t improvereenbarc notlntended orof(ered forsale.If,hewevegthebuildingor TOTAL:
Improvement Bsoldwiihln oneycaiofcomple icoNtheowner-builderwlil have
't-"'FEE
ttqurden of proving that he did not Wild or Improve for purpose s). 'QTITv
Y, y, ,P B RM �.`n" Flppp 7pNE APN
LJ L as Wiideal
owner of the property,am exclusively contracting with licensed pgyp ANE
contractors to mvtruct the project(Sec.7014,Business and Professions,Code:
The Contractor's License Law does net apply to an owner of properly who ALTER I & EM-WATER(EA)
Wilde or Improves thereon, end'who contracts for such projects with a _ y — •--
c�R�[acou(s)licensed pursuant to the Contractor's License Law. �t t c 1,FEE SUMMARY.'`'
IJ I am exempt under Sec B h P C far this reason BACK FLOW #PRO T.DEVICE
Owner Data DRAINS FLOOR ROOF,AREA,COND., SANITARY Y N.
X
'WORKMAN COMPENSATION DECLARATION RECEI Tp gES-PER TRAP SCIiOCL TAX Y_ N_'
❑I hereby affirm that I have a certificate of consent to self-insure,or a' RECEIPT
certlfiuteofWorkers'Cumpevationly mnmoraunifie mpylhemof(Sec. CAS EA.SYSTEM-1 INCAOUTLETS 3800,lab C.I �G7� _^ - PARK FEE Y N
i•- Pollry p ^ GAS EA.SYSTEM-OVER 4(EA) REC[IPT p -
Com any BUILDING DTVI SION FEES
�Certifie cop B herebyhM. GREASE/INDUSTEL WASTE INTERCEPTOR PLANCHECK FEE
❑CertNed copy Bflled witthh the city inspection division.
CERTIFICATEOP EXEMPTION FROM WORKERS' CREASETRAP PAID..
COMPENSATION INSURANCE SEWER-SAMTARY-STORMEA.2001T. Date Remi IN
(Thlsaess.) need netctWbe comompliHed lithe permit B(or one hundred dellen
($100)rtifyt at to the performanceafthe work forw1hich this permit 1,assixted, WATQttIEATERw/vENT/ELECTR ENERGYFEE' Y N
1 shall not employ any person In any manner an u to become subject to the WATER SYSTEM TREATING
Warkcrs'campenaadon Laws at California. Date: / PAID
0Z Applicant NEW RESID[NTfAl IPLMB. SQFf. Date Recei tN
Z O NOTICE TO APPLICANT.It,after making this Certificate of Exemption,you
should become sub}xt to the Wmiceri Compensation provisiooa°(the Labor TOTAL:
C N Cade,you must forthwith complywithsuch Provisions;orthB permit shall be UILD of
LU > deemed revoked.
CL O CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby affirm that there B a construction lending agency for the perform - TOTAL: ELECTRIC FEE
M Z anuoftheworkforwhichthL permtBBs ed(Sec.3097,Clv.C.)
02 Leader's Name PLUMBING FEE
,LL F Lender.Address QTY. , ;. ,MECHANICACPERMIT'✓' ,FEE•f, MECHANICAL FEE '
O W, I ecrilythall have read thisapplicution and exatethatlhe above Information
B correct.l agree to comply with all city and county ordinances and slate laws PERMITISSUANCE FEES PAI
} N reytoenobupont covove,me timudi hereby authorize inspection
this
H Z city to toruponlhcabovcron,andhereby rtyfor bupectlonpatives s. ALTER OR ADD TO MECH. . -
V (We)agree to save,indemnify and keep harneess the City of Cupertino - RIC Receipt
againstllabilitln,judgmenla,coslsandexpenseswhich'mayinanywayaccme AIR HANDLING UNIT(T010,000 CFM) - 'SUBTOTAL;
agalvma Cityinconsequenre egr tin ePermit.
AIR HANDUNG UNIT(OVER 10,000CFN) CONSTRUCTION TAX
S1 ecofAp cant/Comm r to Dale USTHOODM/DUCD, CONSTRUCTION TAX PAID:
HAZARD S MATERIALSDISCLOSURE
Will
the applicant or ful re building occupant store or handle hazardous IiFATING UNIT(TO IDg000 BTU)
rnaicrial as defined by the Cupertino MunldpalCode,Chapter 9.12,and the Date Rmei tH
Heahh and Sa(My Cade Se 32(a)7 I-MATING UMT(OVFR 100,00)BTU) TOTAL:
❑Yes
Will the applicant or future building occupant use equipment or devices VENIILATION FAIN(SINGLE RESID) .,e - ISSUANCE DATE
which milt hazardous air contaminants as defleed by the Bay Area Air
;• Qu Illy Management Di Ind? BOILER-COMPO]-R;DR l00,IXq BTU)
4have mugtibe hexa ou�als requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the W 1venrua Hnalth h Safety Code,Sections 25505;25533 and 25534, 1
understand that if the Wilding does not currently have a tenant,that It B my NEW RESIDENTIAL MECH. SQFf.
responsibility to natty the occupant the requirements which most be met' -
prior once ofa Certificate of pa -
sC.ssitI,,of,,�Cltn�4tino �
- rorauthmiudage
nt D e
TOTAL: ISSUEDBY:�T�1y �'
OFFICE COPY