24425 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect Identification PFRNBTNO.
Building nd0 � 24425
t_rwrrllame:
—
(�ITASUBMITTAL
Y OF CUPERTINO-BUILDING DIVISION 1
Cootr' ' ' 4�o No: APPLICATION I PERMIT LCL-RZ..
- � 1 BUILDINGELECTRICALPLUMBNG-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. Lie.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION PFRMITISSUANCE
I hthSy n7 that)Division
under inessa dPmf hapter9(,,.ndm APPLIANCFSREADENTIAL JOB DESCRIPTION
l'ngwilh5ection 7")of Dtvlslon3ofthe Business and Pro/eulonsCode,and m
icense 1,in ful 1. and effect. PANELS
I,IcenseClas -L Lie.# 4�`2q I Y�VV�r
Date /–d: Contractor
ARCHITECTS DECLARATION 201-1O30AMPS
Roo I understand my plans shall be used as public records OVER 1000 AMPSI W AFFA 5/SQ.FT.
Q 0 Licensed Profesiorui SIGNS ELFLTRICAL I d./ N
6to OWNER-BUILDER DECLARATION SI'FLIALCE(CUIT/M15C
UTER
L, Iherebyaffirmthatlem exempt lromthe Contnctor'slicenu lawf.rthe
�OF� following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.MEEK OR POLE INST. p/�
F� .a c ntywhichrequmapemdttomnstrua,alter,impmve,demolish,orrepalr ,S
OE< anystmu mpdortolos wame,a6 requirestheappbcantfmsuchpermitto POWER DEVICES C
0.0 file a signed statement that he is licensed pursuant to the provlsions of the
u. Contradors License Law(Chapter 9(commenting with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion3o(the Business and Professlore Code)mthat he la exempttherefromand VALUATION
�
`yam'�.'•-1 the basis for the alleged exemption. Any violation of Seaton 7031.5 by any
p<� apphcantfor.permitsubjeds theappilcant to a civil penalty ofnd more than OUTLETSSWITCFESFIXTURES
6a five hundred dollars(y5W). NEW RESIDENTIAL ELECTR
p j�n ❑I,as owner of the property,or my employees with wages as their pule e'RfT SLORIES
TYPE CONSIRUCTION
compensation,willdo the work and thestructure Is not intended or offered for
n sale(Sec 7044,Business and Prolesions Code:The Contractor.License Law
PSS does not apply to an owner of property who builds or improve thereon,and CC.GROUP OZES.(INRs
cess who does such work himself orthrough hisown employees,provided that such
impr.vencnaareno4 tendMorofferedforsale.I!,however,thebulldingor TOTAL:
improvement is.old within one yearof completion,the owner-builderwill have
t men of proving that he did not build or Improve lm purpose ofsala). QTY. PLUMBING PERMIT FEEFLOO Z NNE APN
L as owner of the property,am exclusively contrading with licensed PERMIT ISSUANCE
commonest to mnsec truct the project(S7044,Business and Professions Code:
The Contractor's License I,aw does not apply to an owner of property who ALTER-DRAIN 6 VETQt
Wilds or improves,thereon,and who contrafor - NT-WA
such projects with a (�)
"gNfador(s)Bcensed pursuant to the Contractors License Law. BACX PLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B 6 P C for thin reason
• Owner Date DRAINS FLOOR ROOP,ARFA,CONI. SANITARY Y N_
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have o certificate of consent to self-insure,(Sa FTX7llRFS-PFR TIMI' SCIi00L TA% Y N
certfia
iteo(Workers Compensation Insurance macertifkd rothereof(Sec. RELENT N
3800,Lab Cj, ra GAS FA.SYSfEM.1 INC.4OUTLETS PARK FEE Y N_
Pa11ryM Q "lq(Q-
Com any��copy
FCd. ICV GAS EA.SYSTEM-0VER4(EA) RECE]BUILDING IVISIONFF.ES
❑certlned copy b herebyth the city GREASE/LNDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑CcrtBied copy la fllcd with the city inspection division,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
Rhissectionneed not becompided ifthepemdt lslorone hundreddollas SEWER-SANITARY-STORM EA.2pOFT. Dale Recei t#
(5100)otifyth WATER HEATER W/VENT/ELELTR ENERGY FEE Y N
1 certify that o the pedomunce of the work an as to b this permit is issued WATER
I still not employ any Person In any manner w v to become subject to the WATER SYSTEM/TREATING
O
Workers Compensation Laws we of California.ornia.Date
Applillca.nt PAID
zNOTICETOAPPLICANT:R,aftercru Jd gthb Cedi(icateof Exempt .,y.0 NEW RESIDENTIAL PLMR._SQFf. Date RCCeI t#
Fshould became subjct to the Worken'Compensation provisions ofthe Labor TOTAL:
WW Code,you most forthwith comply with such provisions or this permit shall be
> deert d revoked. BUILDIN -E
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby alarm that them la a comtwdion lending agency for the perform ELECTRIC FEE
Z anceoftheworkforwhich this permit la issued(Sec.3097,Civ.C.) TOTAL:
O O Lenders Name PLUMBING FEE
LL F lamdre.Addm„ QTY. MECHANICAL PERMIT FEE
O W Icertlfythatl have readlhuappBcatfonand satethatthc above information MECHANICAL FEE
S iscorred.l agree to comply with all dtyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
U) reI.ti.gi.building..trodi.n,andhereby..thodze p--t.tivesofth:,
I— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
V — (We)agree to save,Indemnify an d keep harmless the City of Cupedlno Date Receipt#
against liabNtles,judgments,cents and expenses which may N any wayaccrue AIR HANDLING UNIT(TO 10,000CFM)
a tsald City in consequence.(the granting of this permit. SUBTOTAL:
^a_ g AIR ITANDWNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
A
Sig a lent/Contractor Date EXFIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA=01t) SMAT SDISCLOSURE
Wllltheapplicantor/utorebulldm avpant store or handle hazanlous HEATING UNST(TO 1W,ODO BTU)
materlalasdeMedby the Cu moo Municipal Code,Chapter 9.12,and the Date Recei t#
I ie❑alt Yaannd Safety Cod r, elan 2S532(a)7 HEATING UNIT(OVER 100,OOD BTU) To
❑ tax
Willtheapplim rat ortuture building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP Olen OR I OO,0M BTU)
�- I Yes 9 No kkqq,,
haverla thehav et Code, cations 25505 5533 and 25534.
6.95 of BOILER-COMP(OVEli 100,000 BTU) 6Y
the California I lealth k Safety Code,Sections 25505,25533 and 75576. 1
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT �OI!
.P.raibllity to notify the pant of the requirements uireents which most be met IITT y^
prior to issuance of a Certificate of Ocxupanry. 7 /y9Z
CITY nK
Ownm......onud agent Dat.
TOTAL: IssupoBY:
OFFICE COPY