21304 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
building Project Identification PERMITNO.
Building Addre,,: 21304
1 DI Oo T� 2 ,
nera ante: •� ane:
JOSE P&ale- ASSOC ZSS-ZLjq CITY OF CUPERTINO-BUILDING DIVISION 8�QO
c° '"nr.Name: LIc.No; APPLICATION /PERMIT
S029 SS BUILDING-ELECTRICAL-PLUMBING- CATEGORY CONTROL
- ArcMlecl/Engineer. Lk.No: MECHANICAL
QTY ELECTRICPERMiT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 2(�' ❑ ❑ ❑
LICENSED that EO CONTRACTOR'S DECLARATION
1-1
I hercedioby n7OlhafDivisi=3ofheBusiI am licensed under rovbloceofesedosCode,and my APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlthSect1on7000)ofD,j fled o(theBu@Inn@andProfeaslon@Cade,and my
Iimnse
"WAR
e In fu rm Nd d(ect PANELS
License Clam Liex SOS_ S�a_�, 1 rel a
Date�l_ Contrac --->—vUP TO 2DUAMM
ARCHITEC�PFidCCLARATION 201-1000 AMPS
q�v Ore pO I understand my place @hall he used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.FI.
k o U Licensed ProfemlovI SIGNS ELECTRICAL
<�< ° OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
1herebyaffiren that lam exempt from the Contractor's License law for the -
following reason.(Section 7031.5,Business and Professions Any city or Code:A
O e TEMP.METIIItORPOLEINST. f�{' QS
r�„ casntywhich require,.permittococetruq alteg improve,demolish,orrepair ,
anystmmm priortolb issuance,also requlresthe applicant for such permit to POWER DEVICES
IRS 5 file a signed statement that he Is Rcensed pursuant to the provisions of the
3w Contractors Lice.Law(ChaplermmmendngwithSMion70M)ofDlvi-
p g( SWP1hBNG R70L¢GCTRIC
�� elonloflM1e Businemsnd Pro(cssbns Code)orthat he Vexemptthere(romand VALUATION
the basis for the alleged exemption. Any violation of Section 70H5 by any OUILETSSWITCHESFIXTURES
<
applicant fore permltsubpcts the applicant to a civil penalty of not morethen
five hundred dollars($500).
❑I,as owner of the roe NEW RESIDENTIAL ELECTRSQ.PT. STORIES TYPE CONSTRUCTION
property,or employees wages r their
k 7 a atL(SM 0K Businewill do the work anssions ude:T a Coce rridort ended oro(feredf°r
O @ale)See apply to a Business f property
Professions Code:The Contractors Gammen,Taw
S$ dont not apply loan owner ofp rough whobuilds nempor Improwes,yees,povided thereon,and OCC.CROUP RES UNITS
EEEE
who does
mentsa not mself or Intended through his owne.If,ho es,er,thedth t such ing or
Improvementissold Intended mattered sale.lheo no.ItlderwllI have TOTAL: 2
improvementtewld within oneyear°fcomplellorythe owner-budderwillhxve
itdeno(provingthathedid not build or improve for purpose ofuk.). QTy, PLUMBING PERMIT FEE FLOOD7ANE APN
E 1.as owner of the property,am exclusively contracting with licensed
contrectors to construct the project(Sec.70K Business and Professions Code: PERMITISSUANCE
The Contractor's License law don not apply to an owner of property who PETER-DRAIN&VENT-WATER(EA)
build;or Improves thereon, and who contractsfor such pgoje. with a %�_7
FEE SUMMARY
cgn(Tador(e)Ilcenaed punuantto the Contractors Llcenee law. BACK PLOW PROTECT.DEVICE
LJ I am exempt under Sec B &P C for this reason
DRAINS.FLOOR,ROOF,AREA,CO SANITARY Y N
Owner Date RECET N
WORKMANCOMPFNSATIONDECLARATION FO('ITIRFS PER TRAIT SCHOOLTAX Y_ N_
I hereby affirm that I have a certificate of consent to eelf-insure,ora te.x
certificate ofWorkerri Compensatlonlvurance macmilfW ropythereof(Sea
RECb GAS EA.SYSTEM.t INCA DVILETB PARKFTM Y N
3800, a
Po4a
m x GAS EA.SYSTEM-OVER 4(EA) NGDIM
Com any BUILDDI NG DI VISION FF.ES
Certified copy is herebydwith the
city GREASE/INDUSTRL WASTE EPTOR NCHECK FEE
r-1 Certified copy V filed with the city Inspection division.
CERTIFICATEOFI0(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTrARY-STORM EA 2ilo Date Re i t#
RM1lesectlon need nal be compldM tithe permit V(Drone hundred dollars
($100)mlem.) WATER HEATER W/VENT/¢FGTR ENERGY FEE Y N
Imrtlfythatlntheperfornunceofthewmkforwhichthlspen tisWeed,
I shall not employ any person in any manner so as to become subjectto the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PA D
licant
Z Z NOTICE TO APPLICANT.If,after mak!ag l his Certlfiede of Exemption,you NEIV RESIDENTIAL I'LMB. Date Recei t#
Fshould become@ubject to the Wmkers'Compdautlon provisions of the Labor TOTAL:
fA Code,you at fort hwith comply with such provlabv or this permit shall be
> deemed revoked. 1 1 G •
W
G CONSTRUCTION LENDING AGENCY EISMIC PEE
I hereby efflon hat them Is a commuctlon landing agency for the perform-
Z ante.(the work for which this permit is Issued(Sec.3097,Clv.C.) TOTAL; CTRIC FEE
V O Lender.Name PbOMBING FEE
IL F Under'sAddress Qn.1 MECHANICAL PERMIT FEE MECHANICAL FEE
O W tt
Irtlfythd l have read thisappDov
catlorand statethdtheabe Information
1 bcorect.Idgreetocomply with all city and county ordinances and nate laws PERMITISSUANCE FEES PAID: .
} relating to building construction,and hcreby.uthmioarepresantatboe.fthis
I— 2 city to enter upon the above-conuloned property for inspection purposes. ALTERORADDTDMECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cu Fenian Date Receipt#
against Liabilities,judgments,".and expenses which may many way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the grant) ofthl real!.
!� �, d AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
tvreof Applicant/Contractor to EXILUIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupanl@toe or handle haeardous HEATING UNIT(TO I OO,ODO BTU) Date Recei t#
material as dens nod by the Cupertino Munldpal Code,Chapter 9.IZ and the
I❑ Ynd Safety Code,_Sedoon 25532(x)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: �
Will the a pplicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardoue air contaminants as defined by the Day Area Air
Quality Management DIB
District? BOILFR-COMP D 'OR 100,000 BTU)
4 Yee No app
S� have read the haza cans materials requirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU) /rpi1�
the California Health&Safety Code,Sections 25505,25533 and 2534.1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr. r 8 Iflt1(1
responsibility to notify the occupant of the requirements which must be met 4vM,2ZJ��77
Prior to Issuance of a Cer i(Icat°of Oaupanry.
Owner or authorised agent Date
TOTAL: ISSUED DY:
OFFICE COPY