20195 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
,�
Building Project Identification PERMIT NO, .
Building Address: o&05, La RocM V E.� r, - 201C
n
j"'` one: A .GA AJJ
Mi �l Li Z5ri ' ID CITY OFCUPERTINO-BUILDING DIVISION
Contract : Lie.No: 6 APPLICATION I PERMIT ✓[ —
JKW s1S �-24ST- BUILDING-ELECTRICA[.PLUMBING-MECHANICAL CATEGORY CONTROLhillikM
Architect/Engineer. I He.No:
QTy ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ O
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrm that l am ficensed under provisions of Chapter9 immanent APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section7000)of Divislon3ofthe Businessand Pmfe msCode,and my
license is In full
Datf�o�and efect D PANELS V
Lice neilpceLic.M4O Q
1(t(ARCHEaa 201-IODO AMPS
x 1 1 AR shall as RATION OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O 2 I understand my plans shall be used as public records.:
O - SIGNS ELECTRICAL
Licensed Professional '-
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C
i.., 1herebffi
yarm
that am exempt from the Contractor's License Law for the
OOZE^ following reason.(Section7Qf15,Businessand Professions Code:Any city or TEMP METER ORPOLEIN] r - '
F�ppu� countywhich requiresa permit reconstruct,alter,Improve,demolish,orrepair
Fja any structure prior to its issuance,also requires the appbant for such permit to POWER DEVICES
C c.O file a signed statement that he ie licensed pursuant to the provision of the
t 3 ti L� Cantractorb License taw(Chapter 9(commencing with Section 7000)of DIA- SWRAMING POOL ELECTRIC
O ale.3ofthe Businessand Pmfesalora CWe)orthat he is exem therefromand VALUATION
5� San the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES-FIXTURES
applicant fora permitaubj is theappRcant to.civil penalty dnot more than
uc,•y ry five hundred dollar($500). NEW RESIDENTIAL ELECTR SQFL
.- ❑I,as owner of the property,or my employees with wages as their sole LFLCODZONE
TYPE CONSTRUCTION
compensation,will do the work and the.trutture is net Intended or offered for
sale(Sec 7044,Business and Profession+Code:The Contractors Limme Law
$$ docs not a pply to an owner of property who builds or improves thereon,and RFS.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not intended oroffeied for sale.I(howevegthebuildingor TOTA :
improvement bsold within oneyearofcompletion,the owner-builderwili have
th�+rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT APN
L L as owner o
f the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractors to construct the project(Sec 7044,Business ami Professions Code:s The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojens with a ` FEE SUMMARY
Mt snorts)licensed pursuant to the Contractor'.License Law.
LII am exempt under Sec B&P C for this reason BACK FLAW PROTECT.DEVICE
OUTSIDE FEES
Owner Data DRAINS FLOOR ROOF,AREA,CONTI. "2,5 SANITARY Y_ N_
4I WORKMAN COMPENSATION DECLARATION RECEIPT It
1 ❑I hereby affirm certlfkatc o!consen to a nsare,or a FO(IURFS PER TRAP _ SCHOOLTAX Y N
x
<enillateo rs'C rwtion lraurance ora cent ed py thereof(Sec. RECER'rM
38 GAS EA.SYSTEM-]INC.4OUTLETS PARK FEE Y_ N_
1 — RKIBP`rp -
Com any
- GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
�Ccrtfied copy b hereby fumishe . GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
bgCertified copy is filed with tat et IvpMlon division.
/cA_ CERTIFICATE OF FXEMPEION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7WFT. Date Recei I#
(This section need not be completed if the permit is furore hundred dollars
($100)orlem.) WATER HEATER w/vENr/t1.ECTR ENERGY FEE Y N
I mettlythat in the performance of thework forwhlch this permit is blued,
I shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Lawsof California.Date PAID
-
0 Z Applicant NEW READENT AL PLMB. SQ.F. Date Reeei t#
Z U NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisio®of the Labor - TOTAL:
I" N Code,you most forthwith comply with such provisions orthis permit shallhe
W j deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
7
M G Ihereby affirm that there is a construction lendlegagenry for the perform TOTAL: Illi ELECTRIC FEE
Lceoftheworkforwhichthis permit VWised(Sec.W97,Civ.C.) L—1
L1 O Zanders Name - PLUMBING FEE O
F Lenders Addreas - - - QTY. . MECHANICAL PERMIT FEE MECHANICALFEE'
U 1omify thatl have read this appliationand statethat theaboveinformation
W incorrect.I agreeto comply with all tlty,and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
ll relating to building mnstmction,and hereby authorize representatives of this
W cit to entero the above-mentioned propertyfor W ion a ALTFRORADDIOMECH.
? y(We)agree o Indemnify an d eemless the ity of C�nlno Date Receipt#
aga Inst liabilities, costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consryuence of the granting of this permit
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fortune building occupant store or handle hazardous 11EATING UNIT HO 100,000 BTU) Date .RBCeI t#
material as defined by the Cupertino Municipal Code,Chapter 91Z and the - ��
Health and Safety Code�Section 75532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes . ' u No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) pp 1$$UA ATE
which emit havnious air contamlmnts as defined by the Bay Area Air
Quality Management District? BORER-COMP OHP OR 100,000 BTU) �' A
4Yrs ❑Na /1`
haverriaHeat rdoetyCoddabmons2555,2553eand2Mr6.95o! BORER-COMP(OVER100,WOBN) yy/s py ���(r
the Califomla Health Codc,Settloro 75505,5 J3aadt,that 1 3
�„ understandtbatiftbe Wildingdoesnotcorrently ha cotenant,that itEmy NEW RESIDENTIAL MECH. SQ.I•T. 1fN
responsibilitytonni t eoccupantoftherequire ntawhichmust t
1 prior to o ificateof Occupancy._
net or prized cogen e 7YJTAL: ISSUED
OFFICE COPY