23632 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification ' PERMITNO. E_� •aa•//aa,//s
Building Address: Z 3 6 3 Y
LJ Ve'3 5��� er5 c
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�dI Q f i4( 5 CITY OFCUPERTINO-BUILDING DIVISION
Contractor's Name: (I� Llc.N. APPLICATION I PERMIT
SreJ<:S$`N CYCe�. �C{\ aZL N l S BUILDINGELECTRICAUPLIIMBING-MECHAMCAL CATEGORY CONTROLN
Architext/Engineer Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRh9TIS5UANCE �� � � ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffoorthat l am licensed under prevWons of Chapter 9(rommmc- APPLIANCFSRESIDENIAL JOB DESCRIPTION
In cense i Section 70W)of d diedn3o(1he8usinemand Prolmslons Code,and my �
license le In fol rceandeffect. � S� �5 PANELS K�L
License Clam or L
Date Contncior —UP TO 2DO AMPS
ARCHITECTS DECLARATION 20]-1000 AMPS
Z I understand my plain shag be used as pubilc records. OVER I ODO AMPS SQ.FT.FLOOR AREA S/SQ.FL
CO
U(/ Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION PECIAL CIRCUIT/MLSC �~
t„ I herebyaelrmthat lamexempt from the Contracture Liemse lawforthe
Z O. p following reason-(Section 7031.5,Business and Profesalom Code:Any city or
O Z t- alter, ir TEMP.METER OR POLE INST.
any strcture poortorequiress permltmromtmR,esthatortprovgdertmllah,ormit to
any structure poor that
hac aemselso pursue tI.thet forsuchpermltte POWER DEVICES
Q V file a signed statement that he is lk-nsed pursuant to the provlalom of the
O Contncior's License Law(Chapter 9(commencing with Section 7000)of Divl-
f, 0� sion3ofthe Buslnemand ProfesslomCode)orthatheisexempttheTho ad MING POOL ELECTRIC Ice U
the basis for the alleged exemption. Any violation of Soctlon 7331.5 by any
�OSapplicantfora permit sub' thea Bean to a civil of more the UTI-EISSWITCHESSFIXTURES
R hundred dollars($500). pfi
PP PemhY� NEW READEMIAL ELECTR SQ.F7,❑I,as owner of the property,or my employees with wages as their sole �'♦:.CQNSTRUCTION
campers'ion,willdothe work,and the stmchm b not intended or offered for ( ei\V,
siI.Sec.70K Bootless and Professions Code:The cournmeme.License law
S$ does not apply to an owner of property who Wilda or improves;thereon,and t
S
whodoessuchwork himselforthrwgh his own employees,provided that such T'
Improvements are net Intended oroffered forsale.It however,thebuilding or T \ !
improvement lased within-neynamofcomplellon,the owner-bu0derwill have
t rdenof proving that he did rot Wlldorbnperveforpurposeofsale.). QTY, PLUMBING PERMIT FEENE Nr
Lj I,as owner of the property,am exclusively contracting with Ilcenxd PERMIT ISSUANCE
mntractors to construct the project(Sec.7044,Business and Profemlons Code: ��
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT builds or Imprwm therron, and who contracts for such pRojeem with a (EA)
otbacon(a)Ilcenxd pursuant to the Contractor's License I. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
QIlTq.111 11
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RFL[II'f p
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certlflate of consent to self-Insure,w a FIXTURES PER TRAP SCl100L TAX Y N
certl0ateof Workers'Compemationlruurana ora mrti(kd ropythereo((Sa. RECEIPT p
3800,1ab C.) GAS EA.SYSTEM-1 WCA OUTLETS PARK FEE Y_ N
Policy N RECEIPT N
Cb y GAS-EA.SYSTEM-OVER 4(EA) BUILDINGDIVISION FEES
Certrimed ropy is hercbytumGREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
lied copy la filed with thee city inspection division.
CERTIFICATEOFEXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t#
(Thlsxcti-n neM oat W completed Rthe permit islorone hundred dollars
(81I ctor lc h) WATER I-IEATER W/VENT/EIEC ENERGY FEE Y N
Iartify that In the performanaof the work forwhlch this pertnitblasued, —
I$hail not employ any person In any manner so as to become subject to the WATCH SYSTEM/TREATING
Worives C-mPensatlo-Lawsof California.Data PAID
O Z ApplicantZ O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEWRESIDETI
NALPLMB. SQFL Date Recel t#
F _ should become subject to the Workers'Compemation provisions ofthe Labor
WN Cade,you most forthwith comply wilhauch provisions orthis permit shall be TOTAL:
> darned revoked. BUILDING FEE0. 3 CONSTRUCTION LENDING AGENCY SEISMIC FEE Q
I hereby affirm that them las construction lending agency for the perforrry
Z arm of the work for which this permit laissued(Sec.3097,Clv,CJ ELECTRIC FEE
0 Q I`nder°Name PLUMBING FEE ' r
LL ~ Lender's Address QTY. MECHANICAL PERMIT FEE
O W Icertity thatI have read thisNppliation and state that MECHANICAL FEE
information
a bmrrect.I agree to comply with all city and county ordinances and tate laws PERMITISSUANCE FEES PAID:
>- W "IMIngto lou llding mmtruction,and hereby authorise representatives of this
(— Z city,to enter upon the abwcmenuoned property for inspection Purposes. ALTER ORADDTOMECH.
V — (We)agree to save,IndemNfy an d keep harmless the City of Cu penin- Date Receipt#
agd3r IQ4bilitles,judgments,costs and expenses which may In anywayamue ARAHANDLINGUMT(T010,000CFM)' SUBTOTAL
�Nlns d City In consequence of the granting of this permit.
AIRI-IANDLING UNU(OVER IB,BBBCFM) CONSTRUCTION TAX .
l LC
Signature of llam/Conlractom Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will th pith antorfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
miterolas by the Cupertino Municipal Code,Chapter9.t2,andthe _ Date_ RCCe1Dt#
I fe❑alth and SafetyCede, o
Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
Will the applicant oryna future build ing occupant use equipment or devices VENTILATION IAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air corlanore.1$as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU) n
qYs PegB
have rcadthehaa�NO uarmariabrequirementsunder Chapter 6.95 of BOMER-COMP(OVEIR 100,D00 BTU) D
the Czliforrla health 6 Safety Code,Sediom 75505,Z5S73 and 25534.1 mm„�
underst ndTTut Tt bullringdoes-etcomntlyhaveatenarl,that It la my NEWRESIDENTIALMEOL, SQ.Ff pia
map ibllitylonZ� tha ompant of the requirement$which must be rmt Ep 1Q/I�
Trio to issue efT- .Alfiateof Occupancy. I99 /(�
Owner or author CITY pr lot 1, `�y./
Dale 1 t � J
TOTAL: ISSUED BY:
OFFICE COPY
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