21056 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Wentlflotlo^ PERMIT NO.
Building Address:
�,jr lz rn c f 21056
wnera mc: 'O A A
/l� (p—z,3jr� CITYOFCUPERTINO-BUILDINGDIVISION
Contractors Na¢¢FFrr I y��Llpc.No: APPLICATION 1 PERMIT
L./!%mqe -, c ,7•u-a p S BUILDINC-ELECTRICALPLU.MBINC-MECH LAICAL CATEGORY CONTROL#
Architect/Englncer. Lic.No:
/ /J Qct' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ss
Addre :/fo (t7 `�/L 6 . PERMITISSUANCE O ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihembysffirm that l am licenud under provedonaf Chapter9(commmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
huneiainfubnfiance f d of(selcotn3 althe Budneuand Tres(esslomCode,and my PANELSmLLiceCU -9A
Date
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i
9_re, _Gn ContractorUP TO 2DOAMPS
est- wRCHITECused ex LARATION OVERDO AMPS
�Z Iundentand my playsFaBbe used vpublic record a. OVER 10(10 AM[5 SQ.Ff.FLOOR AREA S/SQ.Ff.
COC
ecd U Licensed Professional SIGNS ELECTRICAL
6DI OWNER-BUILDER DECLARATION SPECIALCIRCUIT/hi LSC
7'
Z m I hemby affirthat l am exempt from the Contractor's License law for the
O
following reason.(Section 7071.5,Business and Professions Code:Any city or \TEMP.MEIIR OR POLE INST. Il
Fg� munty which mmqulmaperMttomvrequosthetruct,altc�mpmventfors claprrepair—mitt
4'< any.trudure statement
he he e,also soli pursuant
t the reavokhpermlt a POWER DEVICES
O a O file..igned statement thrt he b licensed punuant to the provtsiov of the
3Contractor's License Law(Chapter 9(wmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC i
I— sion3ofthe Businessand Profemiov Code)orthathebexemptthemfromand VALUATION
4a �'S the basis for the alleged exemption. Any violation of Section 70115 by any
pSO� applicant fora permit subjects the applicant to a civil penalty of nal mom than OUTLETSSWITGIIESFUCIVRES�/ `,(,
w five hundred dollam(S50W. x \ a x
NEW RESIDENTIAL ECTR
7 I,as owner of the property,or my employees with wages as their sole SQFL 51ORIF5 TYPE CONSTRUCTION
ompensation,will do the work,and the structure b not intended or offered for
O sale(Sec.7044,Business and Professlov Code:The Coatradoe•Lt..Law -
S.S does not apply to an owner of property who builds or improves thereon,and \ p R
who does such work himselfor through hlsown employees,provided that such OCCGROIR' RES.UNITS
Improvements are not intended oroffered forsale.If,however the building or �� ^ h TOTAL:
Improvement sold within omyearofcomple iogtheowner-bullderwill have
t4LJNNenofpmving that hedid notbWld orimproveforpurpowofsak.). QTY, PLUMBING.P RMIT FEE FLOOD��B
"L as owner of the property,am exclusively contracting with Iiceved ApNIT.ISSl1ANCE �� x
contractors to construct the project(Sec.7W4,Business and Professions Code:
The Conte does License law does not apply to an owner of property who ' s I
builds or Improves throne, and who contracts for such p(oiedD & WATER(EA)
with a R
,,Ba(t[[adoral licensed Pursuant to the Contradoes License Law. Bs FLOW , OTECT.DEVI E FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason r.\
UUTYIII
Owner DRAINS FLOOR,ROOF,A COND. sAMTARY Y N
IONDate RFCEPT N
WORKMAN COMP ammfinte DECLARATION FLYTURES PER TRAP I SCITOOLTAK Y_ N
Q hereby affirm that I have o lmu ate of consent m spythmre,ora RECENT N
3800,cortif ateofWorkern Compensatlanlvuranceoracertifled copy theren((Sec. GAS FA.SYSTEM-I INC OUTL
],oil lois C.) / 70 PARK F� Y N
I'oliryp _ 6 '537- /`� RECEIPT#
Comm yes Gis GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
I UCertified copy b hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
rL-i�1•drtRied copy b filed with the city inspection division.
CERTIFICATE OF O(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANTTARYSIORM EA 20OF7 Date Recci [#
Rhb sectionneed fid be ENSATI Bthepermit bfor one hundred dollen
(ft 00)orly that
of the WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify thato the person ncenymwork for whichthispermitctissued,
I shall not employ any person in any manner co v to become subject to the WATER SYSTEM/TREATING
Workers'Compensabon law•o(Cb
allfom .Date PAID
0 Z Applicant
_Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQJ.7. Dale Recei t#
should become subact m the Worken'Compevatlon provision of the Labor TOTAL:
WCCN Code,you must forthwith comply with such provisions orthls permit shall be
> dromn]revoked. BUILDING FEE co
EL (] CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform
O ance of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
(,) lender's Name PLUMBING FEE
LL ~ Lender's Addma, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrt lfy that l have read Ihbapplicationand state that theebove Information
Is word,I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N mlating to building constmction,and herebyauthorize repreontalivaofthls
F U) city to enter upon the above-mentioned property for lmpection purposes. ALTER OR ADDTO MECH.
- Me)agree to save,indemm d keep harmless the City of Cupertino Date Receipt#
ag vtllablliti ,judgmenI • dexpenses whit may In anyway acerin AIR HANDLING UNIT(1'010,ODO CFM) SUBTOTAL:
me ui yMcon crop the grant)
MR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
61- Signatu to of Applicant/Contractor ate EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occo pant store or handle hazardous HEATING UNIT(TO t 00,ODO BTU)
rnaterbl as defirmd by tis Cupertino Munldpal Code,Chapter 9.l Z and the Dale RLkei O
1 lea It lilt yes Safety loon 75532(.)? HEATING UNIT(OVER tW,000 BTU) TOTAL:
Will the applies rfuture building occupant use equipment or devices VENTILATION FAN(SINGLE REND) ISSUANCE DATE
which emit hamrd it contaminants as defined by the Bay Area Air
aality Marugcmce LSW BOILER-COMP OHP OR 10LOCO BTU)
(]Yes No PARD
/I
have read th azar o amaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 1��)LLc�JJ
'the California Health&Safety Code,Sections 25505,25533 and 25534. I
understand that if't e' does not cormntly have.tenant,that it b my NEW RESIDEN'TTAL MECH. �.ET. SFrj
rap nsl6Bity to ndity the pafit of the regal menta .must be and {{
pri rto lssu of Ce n£#ieof0ocupa
N•�r� D410Ik11TR
Owner or authorized agent n m7fi— GIt}!G`
TOTAL: ISSUED BY: �I
OFFICE COPY
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