23120 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm ed Identification - PERVITNO.
BUIldbtg Address: - 23120 '
1007S CARMON,�", CO re.-I'irnO
n ams: one:
IlAvj6 X3 5-6/ 7/ CITY OF CUPERTINO-BUILDING DIVISION
can no:°Nine: Lie.No: APPLICATION / PERMIT l /
BUILDING-ELFCTRICALPLUMBING.MECHANICAL CATEGORY CONTROLN
AmMtect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE 1:1 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provision a of Chapter 9(mmmenc APPLIANCFSRESIDENTIAL JOB DESCRIPTION
license
with Sedion 7000)of Division 3 ofthe Business and Pmfesslo siCode,and my -
license I.I.full form aad effect. PANELS
Liana Cho LIcN - Q
Dale Contractor UP TO 2DOAMPS A
ARCHITECT'S DECLARATION 201-1000AM
off+Q ZO I understand my plain shall be used ss public records. OVER IOW AMPS / E/SQ.FT.
E'�� Llanxd Profealorul SICNSELECTRICAL �
fn< OWNER-HOLDER DECLARATION SI'ECLILCBRCUIT/MISC �•
zt., ,wing rasonnthatlam31.5,BsinesseGOatatla/aLkenx law fee the 7�
oo =ntyng icawn.(Section 7031.5,Business and Pimp , Code: h o city it
TFA(P.MECEROR POLE INS!.
��q-U27 mystru urepriulm.apMAMe,mmtvctIres the applicant
to _ .
raj any.tcucture pdortoltshat he it also requlrestuart to
provisions
of to POWER DEVICES i
O E. file.signed.htement that he Is Bo3nwd pursuant to the pmWloru of the
Contractors Lkerute Law(Chapter 9(mmmendng with Section 7003)of DIv1- SWIMMING POOL ELECTRIC
S° aD�,
SOS son of(he Business and Professloru b VALUV Code)orthat he exempt therefromand /the basis for the alleged exemption. Any violation of Section 70315 by any
< OIIILEISSWTICI{ESFIXIIJRFS
applicant for a permit subjects the applicant to a dvll penalty of not more than
O five adreddollars(5500).
NEW RESIDENTIAL ELECIR
�n a.owner of the property,or my employees with wages a.their sole �'FT• STOW r TYPE CONSTRUCTION
pereatlon,w0ldothe work andthe structure land Intended or offered for
c le 01eo 7074,B.Mouse and Professims Code:The Con ewt.e.License Law
�$ does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RFS.UNITS
whodueswchwork hlm.eBarthwgh hi°ownemployeas,provided thatsuch ,
•
mines,ondtsaramtlMendedororferedforsale.ILhowevepthebulldingor TOTAL:
Improvementhwldwithinomyearofc=plelioNtheowner-W Rderwglhave
t rden of proving that he did cad bund or improve for purpose ofsale.). QTY. PLUMBING PERMIT
_jI,as owner of the property,am exclusively contruding with licensed FEE FLOOD ZONE APNPERMIT ISSUANCE
cootndots to co em,et the pro90,ject(Sec.70Bush.and Profe°slmu Code: ..
The Cont®dor'.License Law does not apply to an owner of property who ALTER-DRAIN k VENT WATER(EA)Wilds or Improve° nt
thereon,and who wncte fm such Ispiects with a
�gnj�aetor(s)licensed pursuant to the Contrador'a License Law. FEE SUMMARY
LJ I am exempt under Sec B k P C for this reactors BACK FLOW PROTECT.DEVICE OUTSI DE FF'ES
Owner pra DRAINS FLOOR ROOF,AREA,COND. SANITARY Y ' N
RECEIPT N
WORKMAN COMPENSATION DECLARATION
C31 hereby affipp(TQgpq PER TRAP SCHOOL TAX Y Nrm that I have a certificate of consent to self-Ineurc,.m° RECEIPT M
artiflcate ofWorkea Compensation Insurance or a artlffed copy thereof(Se<. GAS EA.SYSfEM-1 INCA PARK FEE Y T -
3800,Lab Cd' _
Paltry p GAS.EA.SYSTEM.OVER 4(FA) DING DI N
Com any - BUILDING DIVISION FEES
�Cmified copy is hercbyth the ity CREASE/NDUSLRL WASTE INTERCEPTOR PLANCHECK FEE
Certllied copy b(Ibd with the tlty inspection diWalon. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID .
COMPENSATION INSURANCE SEWER-SANITARYP.A.200PI' Date Recel t#
ITeneed cartbecompleted[(the permit bforonehundred dollars
(S1W)or mless)
WATER HEATER W/VENT/R TR ENERGYFEE Y N
Isnot that Nthe ped.I. of the work so ast oh ou permit Is blued,
I shag not employ any person in any manner n as to become subject to the WATER SYSTEM/TREATING PAID
Wormpeneatbn laws of Callfomla.Date
O Z ^ Applicant NEWREEDENTALPLMB._SQyr. Date ReC I#
Z O NOTICETO APPLICANT:If,after ma king this Certifiateof Exemption,you
F N should become subject to the Workers'Comperuatlon provlstom oflhe Labor TOTAL:
Cade,you mast forthwith comply with such proWkare Guth s permit shall be �..
UlC a darned revoked. BUILDING FEE a
CONSTRUCTION LENDING AGENCY SEISMIC FEE -
•4. Iherebyaf0rm that there b a mrutmctlon lending agency for the perform- TOTAL: ELECTRIC FEE
DZ ana of the warkfo'r which this permit b Issued(Sec.3097,Ch,.C.) ' ' ELECTRIC EEE
02 Le.der'.N.me
U. H Lander'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -
O W Icertifythat l haveread thbapplicationand statethatthe above Information,b cones.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} 4 relating to building mustmdioryand herebyauthorlurepresentatheeofthb -
F W city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD]O MECH. '
? (We)agree to ave,indemnify an d keep harMem the City of Cupertino Date Recel t#
V agamallabilltles,)adgmenh, and expenses which may In aoywayacmue AIR HANDLING UNIT CIO 10,"CFM) SUBTOTAL'
against idCit rn conearye of(Z gr.., Me permit.
AIR HANDLING[NIT rovFR 10,000CFM3 CONSTRUCTION TAX
Igw reor Ica / cora '11110 EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAROO MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardousHEATING UNIT(TO 100,OOD BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the Date RLCeI t#
Health and Safety Code Section 255M(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL L
I]Yes No
Will the applicant m Wm building rampant use equipment or devices VENIILATTON FAN(SINGLE RFSLD) ISSUANCE DATE
which nmR haeardous air mntaMnants as defined by the Bay Area Air PAID p 1R.
Quality Management Di�stlrict? - BORER-COMP DIV OR 100,000 BTU) P P9 D -
4hav�read the haraTauaorwterialsrequlrementsunder Cha pter6.95 of BORER-COMP(OVER IOLOBDBTU) DEC ����
the Celifemla Health h Safety Code,Sect lam 25505,25533 and 25534, I _ 1
understand that ifthe building does not currently have a tenant,that it is my NEWRFSIDENTIALMECH. SQ.R
responsibility to notify the occupant of the require nnnb which rmut he and / '
pdortoL uanmofaceoiflateofOccupancy. CITY UF CUPLKII
Owner or aulhorlud agent - Date ISSUED BY s
TOTAL:
OFFICE COPY-.
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