19779 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PEILWT NO.
Building Address: 19779
weans tree / phone: A A
1. CITY OF CUPERTINO-BUILDING DIVISION
c t or'aNa LI N . APPLICATION I PERMIT (or3-'
BUILDINGELFCTRICAL I LUMBING-MECHANICAL CATEGORY CONTROL B
Architect/ neer. Lle No:
QTY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Address:1 _ 5� !S;:S' CA 9 PFRhfITISSUANCE ❑ ❑ ❑ �_
LICENSED CONTRACTOR'S DECLARATION
I hereby eIll.that l son licensed under provisions of Chapter 9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Sento,7000)of Dlvislon3 ofthe Businessand ProfesslonsCode,and my -
licenselsin(ul=r off et et-r PANELS
Lim C as
HITEC�s's1 II�LJ-
Dat Contndor
ARCHITECTS DE pubbc N OVER00 ANTI'S
ce0 2 I understand my plans shag be used ns public reards OVER 1000 AMPS `,/�.FT.FLOOR AREA _ 5/SQ.FT.
O
x Licensed Pmfeasimed SIGNSELEC ICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
p., Iherebya(Otnthatlamexempt fromthe CmBradors Lhxnselaw(arthe
followingreason.(Section 70315,Business and Profesions Code:An d or
O Z F u9 o city TEMP.MEI7➢20R POLE INST.
G�p county which rcqulmapermit lomnstmd,alter,Improve,demogsh,orrepalr
5.'Ii anystrudure prior to its Wuance,alsorequires theapplicant(orsuch permitlo "NFWRESIDENnALELEC
.
Q 3 Gal file a signed statement that he el licensed pursuant to the provisions of the
u, Contractors License Law(Chapter 9(wmemncing with Section 7000)of Divi- SWIMMINGCTRIC
O slon 3 of the Business and Profesiom Code)or that hate exempt therefrom and VALUATION
e. S the basis for the alleged exemption. Any violation of Section 7031.5 by any
appllcantfor a permit subjects the applicant to a civil pewlty of nor morethan FI ES
rgy five hundred dollars($500). LEC❑I,as owner of the property,or my employees with wages as their sole STOW ES7Y1'E CON5IRUCTIONcompensation,will do the work and the structure L nee Intended or offeredfor
does not applyfpmpherem,and
whodues.uthtoanownero(throug hisonem oyee%prvidedt atsuchOCGGROUT' RES.UNITSwM1odoemntsam khimsededorwgh hlsowle.fiLowevrnvidedthatsgmImprovement are not Intended proffered fatale.1(howeveqthebulldingorAL_
Improvement tesold within oneyearo(completion,theowner-builderwill have
t Menof provingthae he did not buildorlmprove for purposeofsa4.). Qry, PL NG RE I FEEFTAOD7�NE APN
L as no,of the property,am exclusively mntnmng with lkxnsed 1aFliMITISSUANC
contractors to construct the project(See 70K Business and Professions Code:
The Contractor's License Law don nd apply to an owner of property who ALTER-DRAIN& TER
builds or improve thereon,and who mntnda for such projects with a
to
ragador(s)licensed pursuant to the Contradeas License Law. BACK FLOW PROTECT. ICE FEE SUMMARY
LJI am exempt under Sec B k P C for this reason
Owner DRAINS OUTSIDE FEES
FLOOR,A ;A CO SANRARY Y N
M1 Date RECEIPT M
WORKMAN COMPENSATION DECLARATION pT%TUREg,PER 7RM SCHOOL 7A% Y N
�I hereby affirm that I have a certificate of consem to eelf-Insure,ora RECEIPT M
rtiBate,of Workers'Compensation Insurance ora ceniBed copy themof(Sec. GAS EA.SYSTEM-11NC.60UTLEIS
3900,La!,C) PARK FEF. Y_ N
I'oliryY� 1 4 BELE N .
C,o�mpany GAS-EA.SYSTEM-OVER 6(FA) BUILDING DI VISION FEES,
I IYenUled copy Ls heed with
the cid. I GREASE/INDUSTRL WASTE INTERCEPTOR \ PLANCHECK FEE
CertlRed copy te(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thissedionneed not becomplded lithe permit t(oronehundred dollars SEWER-SANITARY-STORM EA.200FT. Date Reeei t#
($I00)ales.) in the WATER HEATERW/VENT/=. TR E•NERGYFEE Y N
I¢notemtoyanypef aiaofth nnerwork or to this permit Issued, —
I shall not empty any person In any manner at n to became subject to the
worker;compewadon Iowa of aurnmla.Data WATER SYSTEM/TREATING e PAID
O Z Applicant
Z O NOTTCETO APPLICANT.It,after makingtht CuriRateof Exemption,you NEW RESIDENTIAL PLMB.__SQFT. Date Revel t#
Fshould becomsubjcd to the Workeri ns
Compeation provisions ofthe Labor
N e Code,you comply with such provtiom ortht permit shall be TOTAL:
W > deemed revoked. BUILDING
d O CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Thereby a(firenthae there 3s acerstrudlon lending agency for the perform
af the : ELECTRIC FEE
O nce of work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL
V Lender's Name PLUMBING FEE
LL lanaer'a Aaareaa QTY. MECHANICAL PERMIT FEE OO
O W Icnrtifythahe
lvemadthtapplleallonand Aatethattheaboveinformation MECHANICAL FEE
4 isterred.l agree to comply with all dtyand countyordhan¢sand statelaws [aERMTT155UANCE FEES PAID
} N relating to building wmuuction,and herebyauthorlas reprnenttfvn ofthI,
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MFCH.
Z (We)agree to save,Indemnify an d kap harrtaess the City of Cu portion Date Receipt#
against liabilities.judgment,owes and expenses which may In any wee accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
aga a Id City in ansequ, o he ting thispermie. /�
Y AIA HANDLING UNTT(OVER]Q"CEM) CONSTRUCTION TAX
5 re Applicant/Contractor EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATEAIA ISCLOSU E
WIII tM1e applicant or forum building occupant store or ha 1 a'rardow HEATING UNIT(TO 100,000 BTU) Date
material as defined by the Cu Ino Municlpap Ccs Ls Chapter9.12,and the Reeej t#
IiO Ynd Safety Code Noon 25532(¢)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Willtheepplicant orfuwm building occupant useequipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emithaaardoua air co aMruntas defined by the Bay Area Air
Quality Managenrnt
)it 2 BOILER-COMP(3EA'ORIf10,IXq BTU)
4Yes No
have read the haear pus materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health 6 Safety Code,Sediom 25505,25533 and 25536.I
understand that lithe building don not currently haveatenant that ittemy NEW RESIDENTIAL MECH. SQ.ET.
rnponsibilby to notify the occepant of the requirements which must be mea
rip o' ance of t Cer ificatr of pancy.
r authodard agent
TOTAL: ISSUEDB
OFFICE COPY