23170 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINE; USE BALL POINT PEN 01�16hs
Building Project Identification PLWT NO.
Buildingd �.
23170
ners Mine: s _ one: . A
w, CITY OF CUPERt TINI}BUILDING DIVISION AA
ca^°raanrs Mine: J U FrSLie,No. APPLICATION ffERMIT Cl 2---
BUILDING-ELECTRIc`AL NGMECHAMCAL CATEGORY CONTROL
Architect Engineer: Lic.No: b
QTY EL PERMIFF FEE BUILDING PERMIT INFO
naarca> IC v ' cE F7I �/ yeti
LICENSED CONTRACTOR'S DECLARATION V� L�
Ihereby af(Irm that!aro licensed under provLvlons of Chapter9(rommmc CFSRFct L ]OB DISCRNTION
IngwlthSM)on7000)of Divieion3 ofthe Busneaand ProfemlonsCode,and my
license Is In fun force and effect. NELS
LJcrmc Clam LICS S y—
Dale Contractor 1 Qi�nT �C V.hU 0[e
ARCHITECTS DECLARATION 1-1000
I understand my plats shall be used m public records. OVER 1000 PS SQ.FT.FLOOR ARG $/SQ.
Fi Z Fj Licensed Professional r SIGNS ELECTRICAL l 7 JO
44 Q w OWNER-BUILDER DECLARATIONHurreC
Ii, ES SPECIAL CIRCUIT/MISC
E, J owing rasortn that I Sectio 7MI-S,Basilefrom.sod
License,law fort he
(allowing reason.(Sm1on 70315,Bualnem and Profembrtv Code:Any city or TEMP.MEITR OR POLE INST.
� E'�+ county which requlreaa perMttororstruct,ilter,Unpmve,demollsh,orrepalr
g
OH Mnystmu mpdmtoltsimuance,alsorequireatheappliantforwchper tto POWER DEVICES
E1 Ole a signed statement that he Is Ilmnsed pursuant to the provieforu of the —
� Contractors License law(Chapter 9(commencing with Section 7000)of Divi.
30r^ slon3 ofthe Business and Profesb alonsCode)orthat he exem thefromand SWIMMING POOL ELECTRIC l
S �^ the basis for the alleged exemption. Any violation of SectionreVALUATION
70)1.5 by says WETS-SWITCHES-FIXTURES �••� / t) /3
f� 0� applicant for a permit subjects the applicant toa civil penalty a not morethan O� 0 0
five hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTiON
❑I,as owner of the property,or my employees with wages as their sole
7 rompcnatfon,will do the work Mad thestructure,b am Intended or alteredfor
❑ sale(Sec.7064,Business and Professions Code:The Contractors License Law
$ does not a Fitly to an owner a property who builds or improves themon,and n
who doessuch work himself or through his..employees,provided that such
es'JJ Q
Improvements are not intended or offered for sale.If,however,the building or Improvementbsoldwithinoneyearofcompidion,theowner-budderwRl have
t rden of proving that he did not build or Improve for purpose ofalo). QTY. PLUMBING PERMIT FEE111,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE .i• DATED N
mat racous to construct the project(Sec 7014,Businessami ProfessionsCode:
The Contractor's License Law does not apply to an..or of property,who ALTER-DRAIN&VENT-WATER(EA)
bunds or Improves thereon,and who contracts for such pinjects with a �s FEE SUMMARY
c,,Iln.I..ITactor(s)licensed pursuant to the Contractor's License Law. BACK FlAWPRO"1'ECT.DEVICE
iJ I am exempt under Sec B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF, COND. SANITARY Y— N_
Owner Date RECEIPTS
WORKMAN COMPENSATION DECLARATION FI%TIIRES PER TRAP �r SCPIOOL TA% Y_ N—
❑L hereby affirm that I have o Insurance
a c of consent to opythwre,ora RECm'T Y
certi/ILabc.) orken Compensatlan]vuranceaamrtified ropythereof(gee. GAS EA.SYSTEM-1 INCA OUTLETS PARK FTS Y N
3800,lab CJ —
RECEBT S
Policy S GAS G.SYSIT7d-0VER 4(G) BUILDING DIVISION FEES
Com any
Certified copy is hereby ttheadry
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑cemBea copy vilea with thdry Inspection division. g.� q
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID 6 sK 76t#
COMPENSATION INSURANCE SEWER-SANITARY-STORMFA300F1. Date Remi
(Thissecilon need na b=comple W If the permit b forom hundred aollare
eaffl)orlea.) WATER HFATTRW/VENT/ELECTR ENERGY FEE Y_ N_
I artily
that In the performance of thework forwhlch this permit Is Issued,
1 shall not employ any person In any manner so a,;
to become subject to the WATER SYSTEM/TREATING ^EL
Worken'Compenation Laws of Cebfurnia.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z p NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
should become stabled to the Workers'Compensation provisions mthe Labor TOTAL:
N Codeyou out forthwith comply withauch Provisionsorthia rmitshall be
W > Meemvoed. BUILDING "E I
C
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M O I hereby affirm that there h a construction lend Ing agency for the perform- ELECTRIC FEE
Z ane o(theworkforwhich this permitis lased(Sec.3097,CIv.C.) T AL. 1 _
02 I=ser'sName PLUMBING FEE _ _ ;\
F Lender's Addrem QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE -�
O W Icent.lagethat lhavcrnply read Lithaliotandcion and u tethattnareco sin statellon
a mating t. Wilding complywlth alnd herebydtyandcouhomor nandsand sate laws PERMIT ISSUANCE �� FEES PAID:
} city togtobu lion t che onstruction, authorize representatives o(thLs
F.. N city(We)
ree to ave,Invernally an
property for inspectionCity of Cu e r ALTER OR ADD 70 MECH.
Z (We)agree to save,judgment,
co ty an a keep a.which
the City of Cupertino Date ReOTAL
V
against liabilities,pdgmenta,rose and capensea which rtsy In anywayattrue AIR EIANDLINC UMT H010,000 �" SUBTOTAL:
a —
ga y In Me of the granting of this permit. AIR HANDLING UNIT(OVER 10,000 CF M) CONSTRUCTION TAX
r,,idf$(�t
Sigrutureof Appllan[/Comrador Data ETI IAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bu ading occupant store or hand In hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
P@alth and SafetyCade Section 75537(a)i HEATING UNIT(OVER 1OQ(100 BTI)) TOTAL:
❑Yes � tur
NO
Will the applicant or(future building occupant use equipment or devices ez
VENTILATION FAN(SINGLE RESID) �• ISSUANCE DATE
which coat hazardous air contaminants as defined by the Bay Area Air
— Quality Management District? BOILFR-COMP QHPOR 100,00 BTI)
M Yes to No
have read the harardous materials requirementaunderChapter6.95 of BOILER.COMP(OVER 100,000 BTU) A�
the California Health&Safety Code,Sections 75505,25533 and 25534.1 W
u adersta and that if the build ing does not currently have a tenant,that it is my NEW RM- DINTIAL MECH. SQ.Fr. �s
responsibility ythe ocofthe rtquvementswhich roust'seiner Q 1V 1
prior Lssmnc c'.oVa Certificatete of of Occupancy. ��\s
p
Owner or authorized agent Date ISSUIiD BY: to
TO /�
OFFICE COPY
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