23631 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
- Building Pru en IdentificationPEiRMIT NO.
Building Address: Wit RR 2301
one: AL DAIE
wane CITY OF CUPERTINO-BUILDING DIVISION
c�Rcrant 05.:me' Lic.No: APPLICATION if PERMIT �O
'G BUf DINGELECTRICALPLUMBINGMECHAMCAL CATEGORYCONIROL N
ArcRect/Englocer. Lk.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PFRMITISSUANCE / ❑ }� ❑ 11LICENSED CONTRACTOR'S DECLARATION JOB
I hereby
actionaffirm 0).lam licensed underprovlslom o(Chapter9(rommuc APPEANCESRESIDENML JOB DESCRIPTION
hormieh5ectullfco0)of Dlvialon3o(the Buslnessand ProlnalonsCode,and my
LicamlC1ass forceanLic.8. PANES
License Claw LION
Date Contractor —UP TO 2DO AMPS
ARCHITECT'S DEC ublicm moods. 70LIR1000AS
aOZ ]untlerstand my plan shall be used as public records. OVER]000 AMr5 SQ.Fr.ILOOR AREA S/SQ.FT.
(Qq O SIGNS ELECTRICAL
E'fJ� Licensed Professlorul
<�<La OWNER-BUILDER DECLARATION SPECIALCIRCU1T/MISC
(hereby affirm that am exempt from the Contractor's License Law for the
�gFp following reason(Sactlon 7031.5,Business and Profeselons Code:Any city or TEMP METER OR POLE INST.
IG�+� countywhlchrcqulresaper ttomwttact,alter,Unpmve,demolbh,ormpair
F<��LLg.aa anystmclumpriortoitsL amal,orequlreatheapphmntforsuchpemNtto POWER DEVICES
file a signed statement that M is licensed pursuant to the pmvtsions of the
Owl Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O slon3 elite Business and ProfessionsCoda)orthat he is exempttherefromand
`ur1 6 5 the basis for the alleged exemption. Any violation of Section 7015 by any OU LETSSMTCHESFIXTURES '
[� appHmnt for a permit subjectatheapplicant to a civil penalty elect room than
r, five hundred dollars 001B. NEW RESIDENTIAL ELECTRFr.
.. I,as owner of the property,or my employees with wages as their sole _ STORIES TYPE CONSIRIKTIDN
compeneation,will do the work and the structure is not intended or offered for
O .1.(Sec.7044,Busbess and Profession Code:The Contractors License Law
t
(�I�Q docs not
essuchtoanowner ofproperty
ughhiswho
nemor Improves,y.,prvidedtoryand OCC.GROUP RFS.UNITS
EE who provements am khimsededor fferedowne.If,hoes,p ,tiebuilding or
Improvementsarcnesintended earofco pleio.If,h nee g deer ilI have TOT
improvementisovi within he did et build
improve rpose of sahave
tI�a rdeno(proving that he did no[build orlmprove fur purposeofsaleJ. QTY, PLUMBING PERMIT FEE FLOOD ZAMi APN `
LTL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constmct the project(Sec 7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER BRA)
Wilda or improves thereon,and who contracts for such ptojects with a FEE SUMMARY
coppl1(fadarts)Burned pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
LI1 am exempt under Sec. B&P C for this reason
DRAINS FLOOR,ROOF.AREA GOND. SANITARY Y_ N_:
Owner Dee RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
01 hereby affirm that 1 have•ceNficete of consent to pelf-Insum,ora RECEIPT N
certificate Ofworkers'Compertation Insurance ce a certified copythercof(Sec. GAS EA.SYSTEM--INCA OUTLETS PARKFEE Y N
3800,lab C.) RGCm'I'N
Policy N GAS EA.SYSTEM-OVER 4(EA)
Cam any BUILDING DIVISION FEES
[Certified copy l,hereby furnished.
OCerilfled copy is filed with the city ImpMGREASE/INDUSCRL WASTE INTFRCFTTOR PLANCI-IECK FEE
ion division. IeL 7CH
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP AI W C V
COMPENSATION INSURANCE SEWER-SAMTARy-y-ro ate RCCCI lb
Rhin section need not be completed If the permit is(Drone hundred dollars
(S1W)or less.) WATER IfFAl'FR W/V F7. G 2 WE Y_ N_
I unify that N the performance of the work forwhich this permit Is issued,
Ishan not employ any person In any manner se as to become subject to the WATER sYSlnd/TRFAnNXDATE
Worker%Compensation Laws of Califomia.Date
0 Z Applicant Da Recel tN
Z NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you NEW RESIDIiNTIAL LMB. SQFT.
O should become subject to the Workers'Compensation provisions of the Labor TOTAL:
f N Code,you must forthwith comply with such provisions or this permit shall be
2 BUILDING FEE
deemed revokes. SEISMIC PEE
W — CONSTRUCTION Is a ON LENDING AGCIVCY
11 Ihftheworkfor tthere isaconstmctssued(lending agency 7,Cie. .) perform TOTAL: ELECTRIC FEE
L) ne—
Z anceott Name (orwhkhthis permit l,Lssued(Bee 3097,Civ.C.)
LL O Landers Naar PLUMBING FEE
LL Londe/s Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U
U� tllastatethetel
O w l,cormot.lagrectoccroplywithallcityandccountyordlcancesand satelaws
PERMIT ISSUANCE PEES PAID:
T (L relating to building construction,and hereby authorize representatives of this
W cit to entero n the abovementioned propertyforW Ion ALTERORADDTOMEGH.
I- y(We)agree to save,Indemnify an d eemlcvs the up!nine Date Receipts
U against liabilities,judgments,coesend expenses which 1 anywayacerue ATR HANDLING UNIT QO 10,000 CFM) SUBTOTAL:
age' .ed City In nseyuenu of the Sof it. AICONSTRUCTION TAX
R HANDLING(INR(OVER l0,030 CFM)
. gnat of pliant/Contra Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID: I
HAZARDOUS M RIALS DISCLOSURE
HII eapplicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reeel t#
mat Iasdefinedbythe Cupertino Mur dpnl Code,Chapter9.lzandthe
M and Sa(ety Code Section 25532(a)7 HEATING UNIT(OVER IW,000 BTU) TOT
0 Yo
Will lheapplicantor tuNre building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air conmmlvnts as defined by the Bay Area Air
Qua Illy Management Dist rict7 BOILER-COMP PHP OR I00,000 BTU) -
Yrs No
have read the hares ous material,mquim ents under Chapter 6.95 of BOILER-COMP(OVER 103,000 BTU) �py��AV
the California l lealth&Safety Code,Sect ions 75505,25533 and 25504. I •'•N'11 se Ls
understand that n tifybuilding
occudoes
of nes the
m ntstench,that It is myWmet NEW RESIDENTIAL MECH. SQ.FT nl {/ 1Q/T aY,
resporxsibilitymnotify the occvpa fit of the requlrerrcnta which mart ba rru�t /s /lax�f7Ts`C�/.'l_�
prior to issuance of a Certificate of Occopanry. C'T
�Y Ur 1zU7"CT),
Owner or authorized agent Date TOTAL; ISSIJEDRY:
OFFICE COPY
Robert
E. Rhew 10731 S.E. Powell Blvd.
Vice Presiderd Portland, OR 97266
fun,;A/Ii C-
FAX PHONE
(503) 761-6648 (503) 761-0989
Travel%N9 SNOWS
Just possibly....the world's finest carnival