21372 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification / PFLrnnrN:21372
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naming Aaarcee:
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IMuALLE 51Z N ��oSCJ4 CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: Lic.No: APPLICATION 1 PERMIT l V
Witect/EL Co L ?' WPOD BUILDINGELECTRICALPLUMBINC-MECILANICAL CATEGORY CONTROLC)
21
Archngineer. Lie.No:
L FOCI j[S QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add— HOZ p£RSIAN DZ S mM S PERMIT SSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffbm that l am licensed under provisions of Chapter 9(comment APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Sedton7000)of Dlvlslon3 ofthe Businessand Pm(essionsCode,and my
license Is In full(arae and effect. PANELS
License Claes Lick
Date ContactorUP TO 2DO ANTSs
ARCHITECPS DECLARATION 201-1000 AMPS
Rod I understand my plareshailbe used as pubherecmds OVER IOOO AMPS SQ.FT.FLOORAREA $/SQ.Ff.
mdoG O q
Licensed Professional SIGNS ELECTRICAL la LI Z4
G OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC _l
Iherebyaffimthatlamexemptfmmthe Contudor's License Lawforthe
pp following reason.O (Se Han 7611.5,Buslneas and Pro(essbm Code:Any dty or TEMP.METER OR POLE INST.
muntywhehrequlresa peridia.alsoreuirestheaprove,dem.Rsh,ortr
qq Q any structure priStatement
ento ments that
he is aLcensed remue t to the fro uch inionsofpermit e PDX rER DEVICES
file a signed kens eLa that ha b licensed pursuant it eSe tion 70m) o/ the
�3 G
Contractor's l..License emir Code)(rommencing elseSHon70mfmmanof b SWPIMINGPOOLELECTRIC
O the LA the Business and exemption. Any
f exempt therefrom and VALUATION
<g the barb for the alleged exemption. Any ttola civi.(Stolon 76)1.5 by any
�iOI7ILETSSWITCFiESF1%TUR (�
Applicantvudredaata.($ubjectethe applicant too dull penalty of not more than
flue hundred dollars(g.500).
I,as owner of the property, NEW RESIDENTIAL EL SQ.FT. ICES❑ p perry,or my employees with wages as thele sole TYPECONSTRUCTION
X76 Sam(Sce. loo,willdothe Business and randthesCde:Thure is Contractoret Intended or iceruedfor
$a O sae(..t.ppd,Business Pro(mions Code:The Contractors License Law
doeqs$ whodoesuch roan owner o(property hiscmemorlmproves ovided thatand OCC.GROUP RERUNfTS
whoovementsworktIntendedoroffehlsowne.If,ho eprovidmildisuch
improvementsarcnot Intended caracd(.,sae.I(,however, deer ill have TOTAL:
Improvement V sold within oncyearo(compietlon,theowner-builderwBl have
thA*cden of provingthat he did not build orlmprove for purposeasae.). QTY, P INGP T FEE ptpO zc)NEE
LJ{an owner of the property,am exclusively contrading with Ilcensed ArN
mnt-do-t..ntrudthep.k(Se 70KB--f --.d Professions Code: PERMIT E
The Contradorb License Law does na apply to anowner of property who ALTER.D k V A (E
builds or Improves thereon, and who mntrada for such projects with a A)
on,0_t odor(.)Beensed pursuant to the Contractor's License Law. BAER OT .DEVIc FEE SUMMARY
I_J 1 am exempt under Sec. B 6 P C for thin reason
Owner Date N R F. CO SANITARY Y_
WORKMAN COMPENSATION DECLARATION RECEIPT
N
I'T
01 hereby affirm that I have a certificate of consent to self-Insure,ora PER TRAP SCIi00L TAX Y_ N
certlRcao(Workeri Compansatlonlreurana ora certl/led mpy thereo((Sec. RECEI'f p
3800,Lab C.) G .SYSTEM-1 INCA 0 PARK FEE Y N
polky M —
Co Ccrl GAS -OVER (EA) BUILDING IVISION FEES
5Cenified copy a hereby th thehed. GREASE/IsIDUSTRL WA ErTO PLANCHECK FEE
'(�CerllBed mpy b filed with the dry inspection division. r�Y��j,,�qpa�
�� CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAIDI�I"�O 7 %?i
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t#12)q, Q
1TMa aedbn need not be completed if ted permit d(Drone hundred dollars
(SI Icnrlay.) I. WATERHEATERW/VENT/ELECTR ENERGYFEE Y N
I llnot that employ
an Persian
In
tmannerhAwalk wf.as to become
a mo the
I shall not employ any pen.n f any manner at as to become subject to the
Workcrs'Compensanon laws.(Califome. Date WATER SYSTFh1/TRGTING PAID o-3 C'1 58883 _
O Z Applicant ac�
Z O NOTICETO come APPLICANT:to the
Workers
sko this Certnlateo(ona of
the Labor NEW RESIDENTIAL IP[MB. SQFT, Date Recei t# S`�L�
Code,shoulyou
most
subject the Workers'Such pruasonporthis permit
iMLal he TOTAL:
W Coda you must(onhwith comply with ouch provisions.,thin pemdt shall be
LU > deemed revokes. BUILDING FEE 09
(L O CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I herebyaffirmthatthem isacmu um.n lendingagency farted perform- ELECTRICFEE
Z ante ofthe workforwhichthb permit E issued&c.3097,Civ.C.) TOTAL:
U O %endeenName PLUMBING FEE
LL F Lenders Addrcu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certitythat l havemadthbappllailonand State that theabove information
1 ismrmd.IAgree to comply with all etyand county ordinances and state laws PERMIT ISSUANCE FEES PAID
} W relating to building construction,and hereby authorize representatives of thin
F Z city to enter upon the above-mentioned property for impeckon purposes. ALTERORADDTOMECH.
V _ (We)agree to Save,Indemnify an d keep harm ess the City of Cu pert[no Date Receipt#
against liabilities,judgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(to 10,000 CFM)
sgawt said City in m-sequenm of the granting of this permit. ISUBTOTAL,UBTOTAL:
�� � IO �Sg�g� AIR HANDLINGUNIT(OVER1Q000CFM) N TAX
h%natu Appiam/Contractor Date IXHAUST HOOD(W/DUC'D N TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant orLuture building occupant store.,handle h.,dous HEATING UNIT 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ReceI t#
Healthand Safety Cade Sedion 25532(a)? HEATING UNIT(OVER 100,OD0 BTU)
❑Yea (]No TOTAL: OQ
Will the applicant or tuturc building occupant use equipment or devices VENTILATION IAN(SINGLE RESID) UAppN■yCg.E�DATEwhich emit havrdous air melamimnts as defined by the Bay Area Air II�JQa Illy Management District? BOILER-COMP OEN OR IOQO(D BTU)YesF�N4Mvc,AdthehaAargO materialsmrylrementsti.&,Ch.pler6.95of BORER-COMP(OVER100,000 BTU) 1X1990the California health k Safety Code,Sections 25505,25533 and 25534. Iunderstand that if the building does net currently have a tenant,that itBmy NEW RESIDENTIAL ME(N. SQ.FT.responsibility to notify the occupant of the requirements which must beret aa,��prior to issuance of a Certificate of Occupancy. f� a _Owner or authorlud agem Q11e TOTAL: Q'TIYI`s/ {
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