19924 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEILMITNO.
rr Building Address: / 19924
vera Phone: APPLICATION SUBMFITALA
yam/ �,,Llj CITY OF CUPERTINO-BUILDINGDIVISION
C Me:04. /yam Lie.No: APPLICATION / PERMIT ` l
' �y / �' BUILDING-ELECTRICAL PLUMBING.MECHANICAL CATEGORY CONTROL
Architect/Engineev Llc. o:
J �f QTY ELECTRIC PERMIT FEE BUILDING,PERMIT INFO,-
Addrcaa///0070 /�p�'N/�L /y y11' ��� 1 PERMITISSUANCE �I`-�T,�I
LICENSED CONTRACTOR'S DECLARATION El NP 0
I hereby affirm that l am licensed under provisions of Chapter9(rommenc. MPLIANCESRESIDENTIAL JOB DESCRIPTION
J Ingwlth-cdion7000)of Divlsion3ofthe Busineasand ProfessonsCode,and my
licenseis in full(o a and effect PANELS .sem _ 1"T, r
License Class LIG# O 1 F'-V y,
Date ' C°ntrador 201-1000 AMP'S -
AneshaD be CIPS
DECLARATION OVER1000AW1 FT.FLOOR AREA $/SQ.FT.
00
Zp I understand my plan ahaB be uaed u public records �'
Pd°U Licedxd Professlorul - SICNSELECTRICAL
G LLT OWNER-BUILDER DECLARATION
In f=n SPECIAL CIRCUIT/MLSC
1., Z Thereby alarm that lam exemptfromthe Contractor's License Law for the
G7.Q following reason.(Section 7031.5,Business and Professions Code:Any city or TRAP.METER OR POLE INST.
7I'u9 county which requiresa permit to construct,alter,Improve,derrolish,or repair
anystrudure pdortoitsbsuance,also requirestheappBunt for such permit to
['OWER DEVICES"
O c.O file a signed statement that M is licensed pursuant it the tion 7000) of the
+: t. Contra dor.License law rofessens(cmnoCulerpndng withSectionDWI- VALUATION
H�O� sion3o(ihe Business and ProfesslonsCode)orthat he is exempt therefromand �'A'ENG IC)DL ELECTRIC
�, the basis for the alleged exemption. Any violation of Section 7031.5 by any r� p)a
« OUTLETSSWITCHESFIXTURES L't60C�, V
apeBunt fora permit$5M.tsthe applicant to a dull pemlty,d not more than
F ��o ' five 1,asoundredollars($5M. NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
^^^r��^r^r^r,� I as owner of the property,or he employees with wages r thele sole
Z- ompensa 044,wWdess andwork,and thes Cdumla Conot tractorended o icense offered Law
5 O. sale(Sec 7094,to Business and f property
Cade:The Contractors License Law
$m docs does
apply loan owner ofdprough who nem oeimprowis ovided theme,and OCC.GROUP RFS.UNITS
who d°essuch work him elf or edorough hisoered wnemployees,providedthat such
Improveencnts are issoldintendneyear tcompledonth,owevsgtheerwill have TOTAL:
Improvement isaoldwithlmneyear°lcomplMiorythe owner-bullderwlll have
XpPERMIT ISSUANCE
t eden of proving that ire did not build or Improve for purposn ofsals.). QTY. PLUMBING PERMIT FEE FIAODwNE MNL
as owner of the property,am exclusively contracting with licensed ntradom to construct the project(Sec.7044,Businessand ProfessiontCode:
the Contractors License Law does nor.apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
builds or Improves thereon, and who contracts for such p4ujnts with a
CgR([+ctor(s)umnsed pursuant to the Contractor.License law. FEE SUMMARY
I I I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICEOUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
ner Date RECEIPT#
WOR KMAN COMPENSATION DECLARATION , FU(TURES PER TRAP SCHOOL TAX Y 'N
S
I hereby affirm that I haus a certificate of consent to self-tmurt or a RECEBT#
38WnIabC)Worken'Compewation lrinuranm oracertilled copy thereof(Sec. GAEA.SYSTEM-1 INCA OUTLETS 2.(>D PARK FEE Y N_
RECEur N
1'diry If CAS EA.SYSTEM-OVER 4(EA)
Coypany I _ BUILDING DIVISION FEES
�4.czyi(led copyuhercby famished. GREASE WDU L WASTE QJTFJiCRI'"�OR u PLANCHECKFEE
Cert ied copy is filed with the city inspection division.
CERTIFTCATEOF EXEMPTION FROM WORK ERS' GREASE 7RA]'% PAID
COMPENSATION INSURANCE SEWER- NI.I.`ARYSIDRM E%A 2(10 Date RCCC) t#
TThlsxctbn need not be co IMed if the permit la(�rone hundred dollars
($100)orlm.) � / E ERGY FEE Y N
Icertifythat lathe IN rmanceofthework fo -hich th permit)siaoif, W TER FSEs? �I([VEM FJ.LCTR (] —
I shag not emplo person in any -onee�T,w o me to the WA SYSIFAt/TRGTING
wneker�c mr"R.' GBroenaf p t PAID
—
con
Z Appllurit // NEW RESIDENTIAL PLMB. SOFT. Date Rccei t#
Z 0 NODCE - MI'LICAM:IL aker mkt crtif care emption,you
should become subject to the Workers'Compensation Provision of the Labor TOTAL:
N Code,you rrusst forthwith romply with such provisimetruthi,permit shall be
BUILDING
FEE
deemed revokM.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
O I hereby affirm th it there is a comtructl°n lending agency for the perform- ELECTRIC FEE
Z ince of the work fee which this Permit is mixed(Sec.3097,Civ.C.) TOTAL: `�
02 Lenders Name PLUMBING FEE
1- Lender:Address QTY. MECHANICAL PERMIT FEE
O W Imdifythat l have read this appliutlonand state thatthe above Information MECHANICAL FEE
IL Is corned.Idgree m comply with all city and county ordinances and state laws PERMrr ISSUANCE FEES PAID:
>- N relating to building commaction,and hereby authorize representatives ofthls
t toenteru th nous-mentioned for i ALTER OR ADD TO MECH.
2 "y p°" Pro �rr"°"p" Date Receipt#
(We)agree to ve,indemnify ae.d-keep rMe��s9�/�.f�f�c Cit upertino
V aga[nst) i1h] ,pdgments, dex sea teh may) ywayacenm AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agal i rty in ronsryueom oa ga thla L
�j✓' AIRHANDWNG UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
rc of Applicant/Contrador Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IM,WO B'IV) Date Recei t#
eria'as
defined by the Cupertino Munidpal Code,Chapter 9.12,and the r
IINIthand Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: '� S
❑Yes In No .
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air centamim nus as defined by the Bay Area Air
Quality Managermin District"! BOILER-CDMP DIM OR I W DM BTU)
I Yes �No
Fave read the hoz s not
requirements under Chapter 6.95 of BOILS&COMP(OVQt 100,000 BTU)
the California Health
f;
Code,Sedioro 25505,25533 rad 253d. I
understand that ift building down ntiy hav enanLth Itismy NEWRESIDENTIAL MECH.. SQ.F-F.
nsponsibiIf t Mify the fth Ire swhic stbcrnet ( pl
Acte eLiu cedaCe ca�es ofrnB�O
X—i2I'
ner or authorved age Date TOTAL: ISSUED BY:
OFFICE COPY