23213 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
10ta 06 1t 14 23213
wners //ac�m:
eone;
/x7�UM/' &Aj ' __35/y CITY OF CUPERTINO-BUILDING DIVISION
Cortractor'a Name: Lk.N.: - APPLICATION / PERMIT L
—"DA1AVV UMQ"N OI BUILDING ELECTRICALPLUMBINGMECIIAMCAL CATEGORY CONTROL#
Architect/ gleam Lie.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provIslonsof Chapter 9(commmc- APPLIANCESRESIDENITAL JOB DF ON
Ingwilh Section 7000)of Divlslon3ofthe Buslnemand Profeagm.Code,and my
license ie in ho !cruel d(ect. PANELS
Dd Cl. '- N Lich — s C V D H/
DatLt- Contract. a U I,jy3� —UP TO 200AMM
ARCHITECTS DECLARATION 201-1600 AMPS
q�q�uu is Oqq I understand my pkm shag be used m pubec remrda OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
kzt, Licensed Professional SIGNSELECTRICAL
Q,
< OWNER-BUILDER UIWER DECLARATION
rn F SPECIAL CIRCIIIT/MISC
Zt.., IFereby atflrenthatlam exempttromthe Contractors License Lwforthe
Opp qppp following reason.(Section 7031.5,Business and Profmbne Code:My city or
FZE' mostywhich requmm
la permittomtmct,alter,Improve,demolish,or repair IFMP.METFR OR POLE INET.
g� anydructure prior to its Wuame,ahorequlreathe appliuentf¢ouch permit to
15 O file a signed statement that he Is licensed pursuant to the provisions of the ROWER DEVICES
06
Commerce,License Lew(Chapter 9(mmmenclagwith Section 7000)ofDivi-
�OS si.n3ofthe BuelnmsandPrf..iom Code)orthathe Ise¢mptthemfromand SWIMMING POOL ELECTRIC UATION
O 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any
OU71E1SSWITCHESHXTIIRE9
applicant for a permit subjects the applicant too civil penalty of not mom,than J� •as
$
Eye hundred
owner a.of(hepr. NEW RESIDENTIAL ELEGTR__SQ.Ff. STOKIFS TYPE CONSTRUCTION
<, ❑I,as owner of of property,or he employees with wages se offered
sok
e compensation,044,will thasioes.edhe rendthestmctumhe is ot Contactor or License
Law
5 q sale(Be.(Bee apply to alnow and pro(mlom Code:The or imp Roes L1¢me law
[ $$ dons net apply toanowner of property who WildsorImprovesthereon,and DCC.GROUP RIS.UNITS
0.0.
who doeaeuch a.net mooff imetuirthrwghhbowne.If,he ev.,videdtdl.g ch
Improvement Issold lntenomyearReroct mplede the ner-b deer lding¢ TOTAL
-
Improvement Issoldwithln omycaro(compldbn,tbeowner-builderwlll have
thLIZarden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the Property,am exclusively contracting with license pptMRISSUANCE
mnlractons to construct the project(Sec.7044,Businessand Profession,Code;
The Contractor's License Law dare net apply to an owner of property who ALTER-DRAIN&V[NT-WATER(EA)
builds or improves thereon,and who contracts for such pto)ecto with a
�gW�actoRsl licensed pursuant m the Contractors License Law. BACK FLOW PROT[CT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
DRAINS.FLOOK,ROOF,AREA,00ND. SANITARY ' Y N
• Owner Date RECEBTN
of ¢
WORKMAN COMPENSATION DECLARATION FIX.�ES PER TRAP SCHOOL TAX Y N
I�f hereby affirm that I have a rtlfirate of consent m smrc,ora RECEIVE M
3800Lob CJ
¢rti0¢teolWerkCompensatlonlmunn¢ora¢nlfkd copy pyththereof(Sec. GAS EA.SYSTEM-1 ING<OUTLEIS PARKFER Y N
,
Paltry N_ _ BBC=#
Com an - GAS EA.SYS'PEMOVER 4(EA)
y 1�If RUILUING DIVISION FEES
Certified copy Is hereby filed
the city GREASE/INDUSIRL WASTE INTERCEPTOR4—
z
CHECK FEE
Certified copy Is filed wllh the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWEILSANITARY-STORM EA.20011'. Date Recel t#
(Thlseectlon need net becompleted lithe permit Is!.sons hundred dollars
(SITE)or lm.) WATER HEATER W/VENC/ELECTRGYFEE Y N—
J¢nifythat in the performance of the weak forwhlch this permit Is Issued, JL
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING PAID
Workers Compenutlonlawsof Gllf.mia.Date
O Z Applicant Date Remi t#
O NOTICE
ouldb ca APPLICANT;to
afterrm C..p this Certificate of Exemption'
you NEW RESIDENTIAL PLMB. SQ.FC.
should become subject to the Warken'Compematlon provIsmm of the Labor TOTAL:
CCN Code,you moat forthwith mmpty with such provisions orthIs permit shall be
j deemed revoked. _BUILDING FEE
acorvSTRUC ION LENDING AGENCY SEISMIC FEE
Z Ihercbyaftlrmthat there Ise construction lend Ing agency for the perform, O ELECTRIC FEE
anm of the work for which thIs permit Is issued(Sec.3097,Civ.C.)
00 Lender'sName PLUMBING FEE
LL ~ Lenders Addreu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W ImAllythatlhavemadthlsappBoti...ndnmat
atethattheabovelnforion
bIL ommet.Iagreetocomplywlth allcityand munlyonllnancesand nate laws PERMIT ISSUANCE FEES PAID:
} W
reIdIngtobulldingmnstruction,and herebyaulhorlu representatives ofthis
F N aty to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree I.save,indemnify n d keep harMess the City of Cupertino Date Recei f#
agairutlkbilliam,p`dg nts,co rad expect ylnseywayaceme AIR HANDLING UNIT Q010,000 CFM) SUBTOTAL,
age I Inns en (th a Zing thl rmit fn1 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
1a�
igmture of Appg¢nt/Contraclo Data IXhIAlJST HOOD/W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE.
Wllltheapplicant or future hugding ocmpanl store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date R0Ce1 t#
rtuterkl as defimd by the Cupenlno Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOT
W Yen u No
illthe applicant orfumre building occupant use equipment or devices VEIMI.ATTON FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arco Air
. Qua Illy Ma nagement District? BOILER-COMP(31AP OR 100,000 BTU)
4 Ya 4 No
havoreadthehazar cue matenaIs requhrc.ntsunderChapter6.95 of BOILER-COMP(OVIR 100,000 BTO) Ey
the.California Health k Safety Code,Sectlons 25505,25533 and 25534. 1
understand that if the building does not currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.Er ^
responsibility to not lfy the occupant of the requirements which must be met FEB ���� / 7
p,huto Issuanceda Ce,ificatem Omupancy. �����.....yyyyy''' •1ias�/
Owner or authorized agent Date ISS
IT 1
TOTAL;
OFFICE COPY