24301 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO
j aingAddress: O(Z7H�ZE�.D $ Ll (LE, CLLP �L70 C/-A) 24301
where ame: A A A 11,
(/04Z"0101CITY OF CUPERTINO-BUILDING DIVISION /�1����
Contractor'sName: LIcNN. APPLICATION / PERMIT
00 99;;L BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CON ROL N
rchlled/Engineee Llc.No:
/7�7L '�T O LT? QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Sul O
Address:5//- � PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IturebyeffUm that am Bemaod under provisions of Chapter9(commenc APPLIANCES RESIDENIAL JOB DESCRIPTION
Ingwlthse ion7000)of DlWdon3eftheBminesand Prefe msCode,and my
license I.1.full fo and effect. PANES
License Ca. 12 N_ I
Dale Contractor 201-1000AMP5 �.Q.
LIR IQ 2DQAM2q
ARCHITEGTSDECLARATION OVER1000AMPS E�OOR�$I''Ad S/SQ.FT.
0000m 7_ I understand my plans shall W used as public reconix I 1nV,
Fi L 0 Licensed Prefessioml SIGNSELECTRICAL
a OWNER-BUILDER DECLARATION SPECULCIRCUI7/MISC j
L., 7 I hereby owinguessnn that am exempt from the Contractor's License Law for the
Z S,'�-, following reason.(Section 70015,Businessand Professions Cade:Any city or TB.IRMETERORPOLEINST. / O
0LF- cnuntywhkhrequkeaapermRtomrutr M.1ter,lmpmve,demolbh,orrcpair `
anystmMmpdortoib WuancgaLsorequireatheappUo tf....ch permit to POWER DEVICES
0 E V a VrE=
file a signed statement that he ls licensed pursuant to the provbiors of the
83wG Contractor'sLicense Law(Chapmr9(mmmentlngwith Section 7000)of DWI- SWIMMING POOL ELECTRIC
Non3 oflhelluderss and Profevlmu Code)orthat he a exempt therefmmVALUAand T�;s
Gp57 a 5 the basis for the alleged exemption. Any violation of Section 7001.5 by any OUTLETSSWITCHESFIXCURES 21 -Nye v��e�
applicant for a permit subjects the applicant to a civil penalty d not more than iW
c. five hundred delta.(SM. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
❑T,as owner of the property,or my employees with wages as their sole
compensation,wW do the work and the structure la not intended or offered for
5 p sale(Sec.7044,Business and Professions Code:The Contractors License Law
S$ docs not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
whodoessuchwork Mnself orlhrough hisownemploye,s,provided that such
Improvements are not Intended oroffered forule.If,however.thebuilding or TOTAL:
improvement usold withaoneyearofcornpletio theowner4 Uderwill have
tk,.Il+rdenof proving that he did not Wild or improve for purpose ofub.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct ec the project(S 7044,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who
Wilds or improves thereon, and who contracts for such PNkcts with a ALTER-DRAIN&VENT-WATER
EEN
cgR((ador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L!I am exempt under Sec. B &P C for this reason
OUTSIDE 17CES
DRAINS FLOOR ROOF,AREA,CONI. SANITARY Y_ N_
Owner Date RECFIITp
WORKMAN COMPENSATION DECLARATION FIX.NRFS 1'ER 7RNr sc[ioDL TAX Y_ N_
SII hereby affi m that I have a certificate of consent to self-Insure,ora RECEIPT N
certificate ofWorkeaaL.s'Com/perw"coinsurance
or a certified copytheenn"Sec GAS EA.SYSTEM-1 INCA OUTLETS PARK FFP Y N
3800.LMb CJ t�.L�Ot 3
RECEIPT N
Com any /,d GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
�Certiled copy em hhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CehlRed copy a filed with the city Impe Cron division.
"Y CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Reml t#
(Thisscceon need not be completed If the Former a for one hundred dollars
(SIW)urlr..) WATER HEATER W/VENT/ELPCTR ENERGY FEE Y_ N_
I certify that performance at in the perfoance ofthework forwhich this permit Is issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z 0 NOUCETO APPLICANT.It,a her making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Cod,you at forthwith comply with such provisions or this permit shall be BUILDING 1
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE ISO
a I hereby affirm that there is a construction lendlogagency,for the perform TOTAL: ELECTRIC FEE
Z ante oflhe work for which this permit Ls Issued(Sce.3097,Civ.C.) PLUMBING FEE
V 0 lender.N.nme
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lh
Imdify that]have read thisapplicationand statethateabovelnformation
4 acorrect.l agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ 13. to building coretruction,and hereby amhomm representatives of thin
Zcity to enter upon the abov&mentloned property for Inspection pt'rposs. ALTER OR ADDTO MECH. Date ReGeiptq
(We)agree to save,indemnify an d keep hamNes ca
the City of Cu pert In
V against liabilities,judgments,cons and..per.which may In any wayaccrue AIRHANDLINCUN1T(TOI0,0XCFM) SUBTOTAL:
against said City in consequ ence of the s per
Ing of thimit.
fin_/-r.2 AIR HANDWNGUNIT(OVER lO,WOCFM) CONSTRUCTION TAX
Signature,of Applicant/9rontractorDate EXHAUST FLOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZAR DOUSM TF.R IALS DISCLOSURE
Will the applicant orfuture build Ing occupant store or W nd Is bazardous HEATING UNIT(TO 100,000 BTU) Date ReceI tN
naterlal as defi end by the Cu peeino Municipal Code,Chapter 9.12 and the -
I lea lth and Safety Cede Section 25532(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
�11Ye. M No
ll the applicant or future building o pant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hocardous air contaminants as defined by the Bay Arca Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) k,y AW '
Yes QF�1 Ir No
have mad the hmnacious materials requirements under Chapter 6.95 of BOILER-COMP(OVE2100,000 BM
the Califomu I lealth&Safety Code,Stolons 25505,25533 and 25534.1 oy d
understand that ifthebeildingdom.ot currently have.tenant,that itoccupantismy NEW RESIDENTIAL MECN. SQ.FT -1 Jyq
responsibility to not ify the occupant of the requirements which must be met e
92
prior to tsuanm of a Certificate of Occupancy. [
f17Y0FrftNr,,,,,Y, �(7/7J'
Owner or authorized agent Dale ISSUED BY:
TOTAL:
OFFICE COPY