23566 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES— USE BALL POINT PEN ONLY
Building Project Identification I PERMIT NO.
Building Address: 23566
suns a time: 1 1 my Phone:
A_1 h P r t. B CITY OF CUPERTIN6BUILDING DIVISION
Contractor's Name: Lk,Nm APPLICATION / PERMIT
A _`A _ A _ Furnace Co - 146361 BLnDINGELECnUCAI.PLUMBINC-MECHANICAL CATEGORY CONTROL X
Arohltcj/Engjnrer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMIT ISSUANCE ❑ ❑
LIC ENSEOCONTR under provisions
-
Iherebydf4mthat lam RcenmduMBo.i land Pmfe ao..9(commm APPLIANCESRESIDEN77ALingwity �(OB DESCRIPTION
it...hSectbn7000)and effet.. heBuelnessand Pro(eWonsCode,and rtry j�
Iicenss is in foil(orrn and d(ect.. PANELS W l D l assaaaa
Llcen¢Chao _ 12
Date antnctor_ UP TO AMPS
HITECPS DECLARATION 201-1000AMP5
pkp�vv p❑O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
k b Licensed Profenlaaul SIGNS ELECTRICAL
6C'`4' rkiul OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
z p., I hereby affirm that l am exempt from the Contractor''s License Law forth,
o following reason.I5ectlon 70115,Business and Pmfessbm Code:An city or
OZ I- y ty TEMP.MECNt ORPOLEINST. t ) /
F countywhkh requbesa perrrdttomea uct,alter,Improve,demolhh,orrepalr
anystuctureprbrtoit Wuame,alsorequimtheappBantforsuchpermitto POWER DEVICES
O file a signed statement that he t licensed pursuant to the proalions of the O (/
w Contractor's License Law(Chapter 9(mmmencingwith Section 7000)ofDIW-
1�.++30{{� Non3 oflhe5ueteseand Pre4caloos Code)orthet he is exempt thertfromand SWLTXING POOL ELECTRIC T V LLUA77
6 the haat for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITC:I IFSFIXTURPS
O applicant fora permibubjetts the applicant to a civil penalty of not mare than
$� flue 1,as
neroftdollars(f.500). NEW RESIDENTIAL ELECTR_SQJ-7. STORIES TYPE CONSTRUCTION
I,tie owner al the property,or my employers with wage as their sole
7< compensation,will do the work and the structure is not hatended or offered for
sale(Sec.7044,Business and Profealons Code:The Contractor's License,Law
$ does not apply to an owner of property who build,or improves t harem,and CCC.GROUP RFS.UNITS
whodoes suchworkMmselforthrough hisown employees,provided that such
m
improveent art not Intended oraffered forsale.If,hmvever,thebuilding or TOTAL:
Improvement hsold vithia neyearofcornpIMlon,theownei-bii1derwill have ,
etb.rden of proving that he did rwt build or Improve for purpose ofuk.). QTY, PLUMBING PERMIT' FEE FLOOD ZONE APN
1_I t as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(See 7044,Busmen and Professbro Code: 15 00
The Contractors Lice"Law don not apply to an owner W property who ALM-DRAIN kVENT-WATER(EA)
Wilds or Improve,thereon,and who contracts such p(ojem with a
ryE((+dor(s)Bcensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec B k P C for this reagn
•
OUTSIDE FEE
Owner
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y_ N_nate
WORKMAN COMPENSATION pECLARATION RECEIPT XFKTURBSpERTRAP SCHOOLTAX Y_ N_
QI hereby aRlrm that I have o certificate of consenora
to spytnemn,ora RECEIPT X
3800,.dtficab o(Worken'Compeosatlonlosunnce¢a certified copythereo((Sre. GAS EA.SYSTEM-1 INCA OUTLETS PARKFTB Y_ N_
3800,Lab CJ
Policy X 10121,44222 , GAS FA.SYSTEM-OVER 4(FA) RECEIPT X
Go any B UILDING DIVISION FE IS
Certifiedcop by furnished, GREASE
WASTE INTERCEPTOR PLANCHECK FEE
Certified copy h Ned with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS" GREASE TRAP PAID
COMPENSATION INSURANCE SEWNLSANITARYSTORM FA 200FT Date RL'cel tN
Ohtsectlan need not be camplded I(the pertNt t f¢one hundred dollars
(S100)¢fy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icenot stash anyhe
unce Inan theworkso as to
obeco eenNltblued, 1 O —
i shag not employ any person f any manner n a to become subject to 1M WATER SYSTEM/TREATING
Workeri CompeneaUon Lwe of CaBfomla.Dale PAID
-
zZ Applicant NEW RESIDENTIAL PLMB._SQrr. Date Recel tN
Z Q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workeri Compematlon provisions of the LaborIr TOTAL:
IA Code,you moat forthwith comply with such provisions or this permit shall be 1
`J deemed revoked. —.11VLDING FEE
a0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby efllrm that there h a construction lending agency for the perfomr ELECTRIC FEE
DZ anceo(the workforwhlch this permit t hmrcl&c.3097,Civ.C.) TOTAL: 1, . SO
O O Lender's Name - PLUMBING
LL I-, Lender's Address QTY. `"'MECHANICAL PERMIT FEE MECH
O W1¢rtifythatlhavereadthtapplicatb...dstatethatlheabovcinformation
1 hcorrect.l agree to complywlth all city and county ordinances and Nate laws PERMITISSUANCE S .00 FEES P} relatlng to Wllding coos(nctlm,and hereby authorize repreanhtivesofthio �city to enterupon the above-ntantbned property f¢WpMlon purpoan. ALTERORADDTOMECH. DaRecei tW(We)agree to save,Indemnity an d keep harmless the City of Cu pertlnoagainst liabilitkre,jidgment,swiss and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:go lost said City In con,aqen¢of the granting d this permit. AIR HANDLING UNIT(OVER 10,000CPM) CONSON TAXSignature of Applicant/Contrector Date EXHAUST HOOD(W/DUCT) CONSON TAX PAID:HAZAR DOES MATERIALS DI SCLOSURB
Miltheappllcaat orfuture building ocevpant store or hand le hazardous HEATING UNIT(TO 100,000 BTI) DaROCej t
material as defined bythe Cupertino Municipal Code,Chapter 9.12,and the -O-O--
Heallh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TO
Fly. No
Will theappilcant o tura Wilding occupant use equipment or cinvice, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as dell red by the Bay Area Air a'a p
Quality Management District? BOILER-COMP DLP OR 100,0(10 BTU) Y ey B D
[ph
Yrs ®No
I` a ave read the hazardous materials requlrementunderChepter6,95 of BOILER-COMP(OVER 100,OW BTU) L�jE ��
the California Health A Safety Code,Sections 25505,75533 and 25534. I G p
understan it the building does not currently have atenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT. IV
res po ity n ato(the qulrement which moat be and
to di ofOmu Cy. Orr U"V
q////42,' u7-�„I II yU
neror authorized gent Date
NX
TOTAL: ISSUED BY:
OFFICE COPY