23075 (2) . APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY.
Building Pro'ed identification PERMIT NO.
'Building Ad _ 23075^07C
ser - one: A AL DAIE
s - .2 4 Ola$- CITY OF CUPERTINO-BUILDING DIVISION 1 �
Contract ea: fL�{� LI.No: APPLICATION L PERMIT
1 ' '`"�� _ BUILDINGELECTRICAIPLUMBING-MECHANICAL CATEGORY. CONTROLN
Architect/Engine r. Llc.No:
94– QTY, ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSOANCE 1:1 1:1 ❑s �y
' LICENSED CONTRACTOR'S DECLARATION �_t}
Ihereby affirm,
on700that livlWoA3oftheunder pessand Pot Cssuens9(mmmrnc APPLIANCESRES[DENTIAL' JOB DESCRIPTION
Ingwith S.full 000)of Dlaffect o(the Businneand Pro(esNonsCode,and my - J
Ii mns ie In x d effect. PANELS
License Class
Date CordvctorUP TO 2DDAhTS '
ARCHITECTS DECLARATION 201-IODDAMPS _
po±p CZOq I understand my plana shall be used as public words. OVER I ODD AMPS - SO.FT.FLOOR AREA SM.FT.
Fd Licensed Professiorul SIGNSELECTRICAL .,
G�6 Fkro3 OWNER-BUILDER DECLARATION S['ECIAL CIliC[71T/MLSC
zy, 1herebyafBrmflem I am exempt from the Contractor's License Law Loathe
Ogo following reason.(Section 703].5,Business and Professions Code:An d or f
y city TEMP.METER OR POLE INST.
cauntywhichrequiresapermltwcomu c"ter,Impmve,dc"Hsh,orrepalr
q an ystm=mpdortoiUs ame,alaurequirestheapp0antforsuchpermitto
P ryE file a signed statement that he Islicensed pursuant to the provisions of the POWER DEVICES ,
Q6 3 O t� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC.
.11 elon3af the Buelneeaand Profesloru Code)orthat hebessmpttherefrom and VALUATION
Qthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty of sot more than
five 1,is
demodollarthepro NEW RESIDENTIAL ELECTR SQPT. STORIES TYPE CONSTRUCTION
�n ❑I,a owner of the property,or my,employees with wages r their sok ,
mm(Sec.7 7044,Business
work and the s Code:
Isnot intended oroffered for
doe(Sec.apply
to Wa ow and f property
rope ty Code:The or impdole License Law
dos notapply torn ownecolprough hiswho
nemporimprovntbereoryand that such OCC.GROUP RES UMTS
whoovesweloments are norhimself edorough his own le.If,yees,owe providpraise building
or
tmprovements sdd itis Intendedorsle.ILh ner-g flder illhave TOTAL:
Improvementtseold withinoneysarofcompldbRtheowner-budderwlllhave
tltur en of provlogthat he dldnct build or Improve for purpose ofskJ, QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ Las owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mostmet the project(Sec.7044,Businessand Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for sock pwjmu with a FEE SUMMARY
,Ilt doral licensed Forecast to the Contredoes License Law. BACK FLOW PROTECT.DEVICE
1_J(am exempt under Sec B&P C for this recon
OUTSIDE FES
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N RECEIPT N
WORmthat COMPENSATION DECLARATION HX'NRES PER TRAP SCHOOL TAXI Y_ N_
❑I hereby affirm that i have o Insurance
of consent to copy
thereof
ora RECEIPT N
cedi(late ofWorkers'Compesatlan lrinuranaoaa certi(kd copythereof(Sec. GAS EA.SYSCEM-1 INCA OUTLETS PARK FEE Y_ N_
38W,yLpb CJ a�O�.L RECEIPT#
GAS EA.SYSTEM-OVER 4(EA)
Com any - - BUILDING DIVISION FEES
[�CertlBed copy Is ereby tum she GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cedlled copy ts(Ikd with the tlty Irupectbn division.
CERTIHCATEOFEXEMPTION FROM WORKERS' GREASETRAP PAID
INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
(Thissedion need
COMPENSATION
copletedpermit Is(orone hundred dollars
($100)orles.) WATER HEATERW/VENT/ELILTR ENERGY FEE Y N
I mrtifythat in the performance of the work for which this permit Is blued.
I shall not employ any person in any manner an u to become subject to the WATER SYSTEM/TREATING Workere'Compensadon Lawsof Califomla.Data PAID
O Z Applicant NEWRPADENTIAL'PLMB, SQFT. Date Rece1 [#
'Z O NOTICE TO APPLICANT:E,aNer ma king this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
W Code,you most forthwith comply with such provisions outlets permit shall be
Wj deemed revoked. i. BUILDING FEE
d C CONSTRUCTION LENDING AGENCY 'SEISMIC FEE
I hereby afflrmthat there Is a construction lending agency for the perform ELECTRIC FEE
0 ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL;
Lenders Name - PLUMBING FEE
LL H Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0W
IcedifythatIh vereadthkappUmtionandrtatethatthea'save lnformatlon
ucorrect.[ complywlthalldtyand county ordlnanceeandatale laws PERMIT ISSUANCE �^ FEES PAID:
} 1 relathe With. conatrodion,andherebyauthorizerepresentatives..this
.F.. N cityt enteru the above-men ed property for inspection purposes. ALTER OR ADD TO MECH.
? e)a fire a save,Ind d keep harmless the City of Cupertino Dale Recei t#
V agains b les,' nd expenses which may in anywayaocrue AIR HANDLING UNIT(TO 10,OWCFM) SUBTOTAL:
against icy f egrantingofthlspennt
AIR HANDLING UNIT(OVER 10,OWCEM) CONSTRUCTION TAX
Signature of AppBant/Contractor Data E)(HAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,ODO B'CU)�� /� Date Recei
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCade Section 7.5532G)7 HEATING UNIT(OVER 100,"BTU) TOTAL• �—
❑Yea M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE(DATE
which emit hazardous air contaminants as defined by the Bay Area Air pia
14allty Management District? BOMER-COMP OHPOR ID0,000 BTU) 1 p— A
L��Yea ❑I�No
have read the hazar7i our materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,DDO BTU)
the California
atifth&9fety Cade,Sections25505,25533have
teent that ] C
responsibility
that notifybuilding doesthe occupant
not a currently haves which most b met NEW RESIDENTIAL METH.' SQ.FT Ec"6 1991
responsibility to realty theompant.(Hiss requirements which must be met a.., 'f '
prior to issuance ofaCedlBate o(Ompanry. IL/ (�J• VEc 1
Owner or authwlred agent Date TOiW ISSUED BY. CS v
OFFICE COPY