21124 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY 5(-07-2-y
Building project Identification O y PERMITNO. 1 1 (,I 4
Iluilding Addrcu:
0 3 V0 ( aIA e D-S
.ere ansr: � �p� one: A
(j..�' CITY OF.CUPERTINO-BUILDING DIVISION / B" /���
c tra ore Na Lie.N APPLICATION I PERMIT 1 l
rch En7�rea�r. BUILDINGF2.ECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
C—�I C` Lle.No: BUILDING PERMIT INFO
�b QTY ELECTRIC PERMIT FE,Ey�
Address I'E[ihBTI55UANGE Ls
LICENSED CONTR under rDCCLARATION
54
I hereby Ivia1cnaedanderp enanneof samnsr e,amemy APPLIANCES-RESIDENTIAL JOB DESCRIPTION
It...1 Sectlen7000)af Dlvlslon3 ofthe Buelnemand Profemlon*Cede,nd my
license is In(uy�(opce and effect. 9 PANELS S F D 1 i '
Llcen f�eNLicN� Vr..J
ContnRor
ARCHITECI'SD LARATION 201-1000A.MP5
q�+re0 O I understand my plem*hall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed Professional SIGNS ELECTRICAL I R nam /T
G 6
OWNER-BUILDER DECLARATION J
a SI'ECGL CIIiCU1T/M1SC
ZI-'iAa owing rason.ihaton 7031mptfmmlhe ContradsionsCde:LawAny Ionise
qqqqqq following rehmqui mlon 7n3tto Business and Professions Code:h, cityor
F s'� countywhlch rcquiresa permit toconsWgalter,Improve,dennWh,orrealr 7RMP'MEfIR OR POLE INST.
a any structure priortoile lesuance,alsorequlrealhe applicant for such permit to POWER DEVICES
V file a signed statement that he Is licensed pursuant to the provisions of the
Gq Contractor's License Law(Chapter 9(commencingwith Section 7000)ofINA-
��0 slon3ofthe0usinessacad PrefeeslmsCode)orthat hebexempttherefromand SVIB`iMINC IDOL ELECTRIC VALUATION
G the basin for the alleged exemption. Any violation of Section me m re any OLI'MrTSSWITCHFSFIXTURES I Lid �u
applicant for the permit exemtheption,
n, Any
t to violation
penalty n not .5 by hanany
five hundred doll..(5500). NEW RESIDENTIAL ELECTR
7 6
mmpensatl
n I,as owner of the property,or my employees with wages a their*ole SQFr. STORIES TYPE CONSDIUCTION
on,wllidothe work andthestroclun brmt Intended or offered for
O sale(Sec.7064,Buelnae and Professions Code:The Contractors License Law 1
[ $S3 does not apply to an owner of property who Wilds or improves thereon,and OCC.CROIIIa RFS UNITSC; who dose such work himself or through his own employees,provided that such
Impmvementa are nm Intended oroffered for sale.If,however,thebuilding ce TOTAL; I
Improvement hold within oneyearofcompleliogtheowner-buRderwlll have
t119JZurden of pmvingthat M did not build or Improve forpurpose ofsale.). QTY. PLUMBING PERMIT FEE FLCODZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE .M
contrectos to coamuct the project(Sec.7044,Business and Prefa*lans Code: a�
The Contractors Llmnae Law does not apply to an owner a property who ALTER-DRAIN k VEM-WATER(EA)
builds or Improves thcd
eon, and who contracts for such ptujea with e
cgyTactor(a)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_I f am exempt under Sec. B k P C for this mason
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N_
• OUTSIDE FEES
Owner Dam RECEBrf M
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
QI hereby affiWorkers
that I have o certura c of consent m copy thereof
or RECEIPT N
certl,ILAbC.cate of Worken'Compensatlan Laurance ora certified copythermf(Sec. GAS EA.SYSTEM-I INCAOUTLSTS PARKFER Y N
Policy
lab C3
Comn GAS EA.SYSTEMA RECEIPT M
Y BUILDING DIV SION FEES
Certified copy is herebydwith the
ed,city GREASE/INDUSTRL S r I-IECK FEE
Certified copy le filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
1
COMPENSATION INSURANCE SEWER-SANTTARV-STO /� Z �[ Date RCCCI t# I 1 n]I
($10T.,lea.) W
(Thlseedlon need not be completed If the parrot V(mom hundred dollarsm RGY FEE Y
I cedifythat m rm
the performance of thework forwhlch this pclt is WedWATER HEATIB4 W/VENT/ FC Nu
, N—
I shall not employ any person in any manner so as to become subject to the WATLR SYSTCM/TREATING
Workers'Compensation Iowa of Callfornla.Date PAID
-
zZ Applicant Date Recei tff '
Z O NOTICE TO APPLICANT. after making this Certificate o(Exemptlon,you NEW RESIDENTIAL PLMB. SQdrI.
should become subjectto the Workers'Compensation provisions of the Labor TOTAL:
W Code,you most forthwith comply with such provisions or this permtshall be ( BUILDING FEE
`> deemed revoked.
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
Z ance of the work for which this permit is Banned(Sec.3097,Civ.Cd TOTAL
(� O bender.Name PLUMBING FEE
IL F- Lender'.Add.ea QTY. MEC14ANICAL PERMIT - FEE MECHANICAL FEE
OW I certifylhat l have read this application.Mtlatethattheabovemformatlon ,p�
IL tattered.I agmEW comply with all city and county ordinances and Elate laws PERMIIISSUANCE (50 FEES PAID:
>- N mi.tingtobulldingcoatrvctlon,and herebyauth.ham.prexentativeeofthle
Z city to enter upon the above-mentioned grope for in spectlonpurposes. ALTER OR ADD TO MUCH.
(We)agree to ave Inde-ZI d lees rMess the City Of Gu pert on Date RCCCjptM
L) agalatllabllitles,F is, cad so whichmaymanywaya a AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL: l
Zino Ci consequ oft .n ng his
Permit.
AIR HANDLING UNR(OVER IO,000CFM) CONSTRUCTION TAX
AdMoc of App C0'0tmtar e
EXHAUSTHOOD(W/DUCD CONSTRUCTION TAX PAID: aP�
AZAIf US MATCRIALSDISCL SUR
Willthe pllcant or future building occupant store or handle haeardou* HEATING UMT(70100,000 BTU) D�•
materlaladefinedbyth.Cupedi.o Munldpal CodGChapter9.lj.endibe _ Date RCcel tN
Ilealth and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
Ry.Yas r]No _
Ill the applicant or future building occupant use equipment or dev. VENDLATION PAN(SINGLE RFSID) ISS ' ATE
which emit hazardous air contaMants ase defined by the Bay Area Air,
. Quality Management District? BOTLER-COMPQHPOR 100,0(10 BTU) rl>•i/R � �
V. n❑No
Thaw read the hazardauamaledals requirements under Chapter 6.9S of BOILER-COMP(OVER 100,000 BTU)
the Glif.i.Flealth A Safety Code,Sectlaa 75505,25533 and 25534.I
understand that 11 the building time not correctly have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Fr.
mponsibllity to notify the occupant of the requirements which mu at be met - HI•�gl...IM fa
prior to Issuance of a Certificate of Occupancy. L
Owneror.uthodndagent DateTOTAL: 1113�G�f
ISSUEDBV: WL'/Ir lsrr e'er^� "g
OFFICE COPY