23929 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USEBALL POINT PEN ONLY
Belittles Pro ect Identification PIRMITNO.
Building Address:
0o 23929
i Nair a
Ownera ante: 6 _ one:
CITY OF CUPERTINO-BUILDING DIVISION
Lie.No: APPLICATION / PERMIT
S BUILDINGE.ECTRICALI'LUMBING.MECHANICAL CATEGORY CONTROL#
Arcit / gioser. LIC No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCEEl 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son licensed under provisions of Chapter 9(comment, AMUANCES-RESIDEN71AL - JOB DESCRIPTION
Ing with Section 7000)of DiAk=3 oflhe Boadoessand Profesai.naC.de,and ray //
B...le In full fora and affect. - PANELS a vu y
Llmn.0 as - ic.# 3?e 3S9 AfP,nA
Date Conracter �.e^7yL.cf$
ARCHITE DECLARATION 201-1000AMPS
Z I unders slid my plane elyg be used n public records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
f']�. _l _
Limn Pro(embml SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION P
rG�f a SPECIALCIRCIAT/MLSC I' ,( iI'_' f
Zp, Iherebyafflrmthatlam exempt from the Contractors License Law for the E D
Afo0owing maaon.(Section 70115,Business and Professions Code:Any city or
TEMP.MEfFR OR POLE INST.
au,muds hrequlma permitissuan rommrruct,alter,equinnithea pmve,dennWh,orrepair outto t e�
an,slgnere prLortoistatement
ehat he is licensed
pursuant t lithe forpro inionsuch of tro POWER DEVICES L�
floe a algned mens ent that he t r 9(coed pursuant it the provisions of the `
3w
Contractor's Lkertx law(Chapter9(mmmencing with Section 7f100)o(Divi. b
OJ sion3 ofthellu.inessand Profemlom Code)mthat hats exempttherefromand SWIMMING POOL ELECTRIC
ATE ATION
y.'•7 the bash for the alleged exemption. Any violation of Section 70115 by any
0� OUTLETSSWITCIfFSFlXTURES
$� applicant for a permit subjects the applicant to a civil penakyof net morethan
five hundred dollars($50(E. NEWRESIDFNIIALELECTR
�n E]1,as owner of the property,or my employees with wages as their sole SQ'FT' STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure h not Intended or offered for
O tole(See 7014,Business and Professions Cede:The contoct.e.License law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUIa RES.UNITS
who does such work himself a through his own employees,provided that such
Improvements are not intended...ffered for sale.If,however,thebuilding or TOTAL:
Improvement i.wldwithlnemyearofcompletiorytheowner-bu0derwillhave
14LItircien of pmving that he did net build or improve fee purpose ofsale3. QTY, PLUMBING PERMIT FEE FLOOD TONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044.Businessand Professions Code:
The Contractor.License Law don nor apply to an owner a property,who ALTER-DRAB)&VENT WATER(EA)1 Wilds or improves thereory and who contracts fee such p(ojects with a
cga(ractor(a)limned pursuant to the Comractne.Laom.Law. BACK FLOW PROTECT.DEVICE
SUMMARY
U I am exempt under Sec B&P C for thin reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDE Fr
Owner Date RECEIPT#
WORKMAN COMPENSATION DECLARATION PER TRAP SCHOOLTAX Y N
Or
hereby affirm that I have a certificate a pIX.�
of consent to self-Insure, a RECFR NI
este of Workers'Compensation Insurance or a carjBW copy thereof(Sec. GAS F.A.SYSTEM-1 BJC40IJTLEIS PARK FFP Y N
OO,Iab C.I,a�y�, p
Po11ryM '+ .,Yl.KY9' a� / �o�'y RECEQ'TM
LZ� �/Fgyt GAS EA.SYSI'FM-0OVER Com anv �f BUILDING DIVISION FEES
IlCerifledmpytshereby/umlahed. GRGSE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
emiied copy h at filed with tcity Inspection division.
CERTIFICATE OF EX T:MPTION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 2(017. Date Reeel t#
R .on need not lx complcted lithe perndt ts for one hundred dollars
($]00).rorless.) - WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I artily thato the Person
ofthework so an to bco eermit subjts to the
I shall not employ any person ro any manner so u to become abfM t°the WATER SYSTM/TREATING
Workcrv'Compenutlon Lim of California.Date PAID
O Z Applicant NEWRESLDENIIALPIMB. Date Recel f#
Z O NOTICE TO APPLICANT:If,after making this Certificate
of Exemption,you
should become subject m the Workers'C.mpensatlon Provllte of the Labor I TOTAL:
Vl Code,you est forthwith comply with such provlelons°rlhis permit shall be a�
W j deemed revoked. , -BUILDING FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby aftthattheretsa comtmttion lend ing agency for the perform- ELECTRIC FEE•
Z anceaf the werkfor which thhpermit ie issued(Sec.3097,Civ.Cd TOTAL:
V O Iaruice-Name PLUMBING FEE
IL t- Landers Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mnlfythat l have read this•pplicati°nand.tatethauheabove Information
1 Jammed.I agree to complywith all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>- W relating to building construction,and herebyauthorine repmeentativesofthh
I.- to the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z mDale Ri t#
z (We)agree t°save,indenify an d keep harmless eceP
the City of Cupertino
against liabilities,jadgments,msts.nd..Pa...which may In any wayaccrue AIR HANDLING UNIT(TO 10,(0)CFM) SUBTOTAL:
against•aid CVf in consequ�of the tingathl.permit.
7AIR HANDUNG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
51 are of Applicant/Contract •h rTp4 EKHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR DOUS MATERIALS DISCLOSU{E /
Will the applicant orfuture building occupant store or handle h=rdous HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chaptcr9.lZ and the
I Iealth and Safety Code Section 25532(a)T HEATING UNIT(OVER 100,000 B'TU) TOTAL.
Y. M No
dl the applicant..future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hacard ab contaminants as defined by the Bay Area Air II��
Quality Management
ement District? BOILER-COMP DFB'DA 100,000 BM #' A
r ave year-1No
have read the havrdoua materials requirements under Chapter 6.95 of BOILER-COMP(OVIR 100,000 BTU) JUL
the California Heigh&Safely Code,Sections 25505,25533 and 25534, 1 1998
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT - y
.nponsibility to notjfy the occupant of the [cements which ma at be mat
m
pris .Issuance aCertlficateof p t ,TTY OF Curt
Owner or aul orived agent D/ac ISSUED BY:
TOTAL:
OFFICE COPY