23388 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PETLVETNO.
Banding Address: ,4 .ass _ - 23388
Ownue8190
ooame: one: A A A
J�u 'C_ (.(- CITY OF CUPERTINO-BUILDING DIVISION
Contra .rawme: Lic.N.: APPLICATION / PERMIT
OYETa¢} IKNM�N•t 35(4,046 BUILDINGELECTRICALPLUMBINGMECFIANICAL CATEGORY CONTROL N
Architect/Engineer. Lic.No:
�- l QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:`�'f�! F WA�!
PERMITISSUANCE ❑ ❑ � ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under pmvWU ,n&of Chapter 9(comment, APPLIANCESRESIDENITAL JOB DESCRB'T'ION
ingwith Section 7000).!Dlvia.n3o(the Busiuya ProfesurraGode,andm
license is in(u tree d effect U PANELS '
Liren Ch Lic.N 35�
Date - `I` Contractor Z UP TO 200 AWS
ARCHITECT E LARATION 201-1000 AMPS
q�+a0 I understand my pons shall be sed m public records. OVER 1000 AMPB �S.Ff'.FLOOR AREA S/SQ.FT.
'cG Licensed Professional / SIGNSELECTRICAL A L E D �.I�
<<� OWNEReBUILDER DECLARATION rs
�n Fn SPECIAL CIItCIJIT/M15C I\V/'
(.., / owingraf@mSectio 7exemptfromthe Contractor's License Law fort he
7 O_'� following reason.(Section 7Q11.5,Business and Professions Cade:Any city or
O 2 ti TEh1P.METER OR POLE INST.
cwntywhkh requiresa pemettoronstmci;alter,Improve,demolish,°rrepair
UTER
q .a anystructure Inform its issuance,also requlrestheapplicant forsuch perndtto POWER DEVICES TE �O
G' F file a signed statement that he is licensed pursuant to the provisions of the
3 w Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- ylypd,YgNG POOL ELECTRIC H O si.n3o(the Buslnemand Professions Code)orthat heb exempt therelromand VALUATION
the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWITCHESFTXT(IRES
L rj O<e applicant for a permit subjects the applicant to a civil penalty of not mare than
five hundred dollars($SM.
.. ❑I as owner of the ro or m employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
• P perty, Y scop oYe B
� < compensation,will dothe work and the stmcmm is not intended or offered for
i O sale(Sec.7014,Business and Professions Code:The Contractors Liceme Law -
P$$ does not apply to an uwnerof property who builds or improves thereat.and OCC.GROUP RFS.UNITS
who doessuchworkhimself orthrough hisownemployees,provided that such
Improvements are not Intended oroffered forsale.If,however the building or TOTAL:
Improvement6s ldwithin°neyear.fcompletiogtheowner-Wnderwillhave
the Wrdenof proving that he did not bund or bnprove for purpose ofask.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
❑L as owner of the property,am exclusively contracting with licensed ' PERMIT ISSUANCE
contractors to construct the project(Sec.7034,Business and Professions Code:
The Contractor's License Taw does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)Wilda or Improves thereon;and who contracts for such projects with a FEE SUMMARY'
on trachms)licensed pursuant to the Contractor's License Law. BACK FLOWPROT[CT.DEVICE
I am exempt under Sec B k P C for this reasonOUTSIDEFFES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N..
WORKMAN COMPENSATION DECLARATION F0(TURES PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have o Insurance
of consent to copy thereof
ora RECEIPT N
3800,Lab of Worken'Compensatlon Wurance oracertified ropythereof(Sec. / GAS EA.SYSTEM-1 INCA OUTLETS PARK FIE Y N
Polis If l - RECD,p
Policy p CAS EA.SYSTLM-OVER 6 MA)
Com any BUILDING DIVISION FEES
Certified ropy It hereby famished. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
F-1 Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Rett'IPt#
(rhissection need not be completed tithe permit Ls from hundred dollars
($1f10).r les+.) WATER HEATER W/VENT/ELECTR' ENERGY FEE Y N
I certify that In the performance of Ne work f.rwhich this permit b issued,
I shall not employ any person In any manner so as to became subject to the WATER SYSTFTi/TREATING
Workers'Compensation Laws of Califomla.Date PAID
—
ZZ Applicant NEW RES DEN ALPMB. SQFT. Date ReCel t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
Hshould become subject t.the Workom'Compemation provisions of the Labor TOTAL:
W Code, must forthwith comply with such visions orthls permit shall be,
W > deemed revoked. P4, pro BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a herebyafOrmtaOhere acons uctt°niendngagenryf°rtMp orm ELECTRIC FEE
Zancoofthe work forwhichthb permit is Issued(See.3097,CIv.C.)
02 lenders Name 1--) PLUMBING FEE
1= ]e.do aAadn,� QTY. MECHANICAL PERMIT FEE
LL U MECHANICAL FEE
-1 rertffy I hav ad this appliatlntl
miand gets that the inforu .n
t '
0 W Ismrrect agree comply with all and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} a relatin oWi ng conetructlon, hereby authorize representatives of this
~ W cit enter o theabove- toned ro for inspection sea. ALTERORADDTOMECH.
Z Y e) pto save,Ind fy an d keep�mless te City of Cupediao Date Receipt#
_V afro abilitie Pdg rostsand expenses which may In atywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ago' t inesofthe granting of Ws permit.
en /y n AIR HANDWNG UNIT(OVER IO,WOCFMI CONSTRUCTIONTAX
Signature of Applicant/Contractor Date Z Exrwusr HOOD(W/DUCD CONSTRUCTION TAX PAID:
` HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllcantorfuture build Ing occupant store or ha lid le hazardous HEATING UNIT(TO IM000 BTU) ,Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Cade Section 25532(.)7 1[EATING UNIT(OVER 100,000 BTU) TOTA —
• ❑Yes In No '
Will the applicant or future building occupant use equipment ordevnax VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which enter hazardous air contamimnts as dented by the Bay Area Alr p pp
A
Quality Marugemant D❑Wrict7 BOILER-COMP OHP OR 100,0(0 BTU) IO I D
No
4havereadthe I,azard.us materials requirements under Chapter 6.95 of BOILER-COMP(OVER IDg0(0SM)
the California I lealth&Safety Code,Sections 25505,25533 and 2 W 5536.1 "• 1992
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. ,pye'AR -SQ.ET.
responsibility to nosily the occupant.f the requirements which must be met
prior to esua nce of a CsAffiate of Occupa nry. C11 YY�yUf-NUu t-L'l l�
Owner or authodred a gent Dae ISSUEDOY:
TOTAL:
OFFICE COPY