23462 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Buildirm Project Identification PER H*NO.
Building Addresr
Jirna,` w � 23462
sera anr•. one A A A
CITY OF CUPERT[NO-BUILDING DIVISION I 1
cant ctoraNanr: /1 ,. 1 Lie./.: APPLICATION /PERMITAil� `l "l
11(I BUfLDING-ELECTRICAUPLUMBING-MECHAMCAL CATEGORY CONTROLN
qW Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre,c PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihthe ifflrmthatlamuam3oftheesiprovision.Adl'ro Chapter 9de,and nc APPDANCFSRESIDENTll+L ]OB DESCRIPTION
In arse is in full force of d effect.
Pm/oalonsCode,and my
Iicense b in full force and affect PANELS �
DrehJE" 5.1275 e'• oUr W' ff
DaCarl do
?011000 AMPS
ARCHITECTS DECLARATION OVER1000AMP5 SQ.Ff.tLOORAREA $/SQ.FT.
qOd ]understand my plats slug be used upublic records. a..
E Licensed Professional SIGNSELECTRICAL FDNA f,L, E—: D
�¢ OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC 1✓ 1 1 ^
L., IhercbyalBrm that l am exempt from the Contractors Luense Law for the A Ul E K
Z� 'y following mania,(Section 7031.5,Business and Pm(essions Code:Any city or TEMP.METER OR POLE INST. ))) RR, 111
x.54 u� =ntywhlchrequuesapert tt.mmtmd,alter,impmve,dennlish,ormpair /'/ /�s
ofe 1 aeystructure prim to its issuance,also requireaiheappllcant for such permit to POWER DEVICES ` (7 ` a...
file a signed statement that he is licensed pursuant to the provisions of the
Contractor'.License Law(Cha er 9(commencing withSection 7000)ofDivi-8�0¢ sion3oftheBusiness and ProfassionsCods)orthatheisexempttheraharria SWMMINGPOOLELECIRC VALUATION
Q 5 the basis for the alleged exemption. Any violation of Section 7¢31.5 by any OUTILETSSWITCHESHXTURES Vol
apphant for a permit subjects the applicant to a civil penalty of not more than
R� five hundred dollars($500). NEW RESIDENTIAL ELECTRSQFF. STORIES TYPE CONSTRICTION
6 ❑I,as owner of the pmperty,or my employees with wage as their side
compensation,wiRciotheworkandthestmcturebmt intended or offered for
ya ❑ sale(Sec.7014,Business and Profesaims Code:The Contractors Umnse Law -
ps� does not apply to an owner of property who builds or improves themon,and OCGGROUP RIS.UNITS
w who does such work himself orthrough his own employees,provided that such
improvements are not intended oroffered for sale.If,however,the building or TOTAL:
improvement is sold within ane yearofc.mplelWn,the owner-builderwill have
th rdenof prving that he did not baud or improve for purpose ofsileJ. QTY. PLUMBING PERMIT FEE
FLOODZONE APN
I,as owner of the property,am exclusively 04,Business
contracting with licensed PERMIT ISSUANCEcon00
The Contract mnswn the project(Sec.apply
to an
and Iof properly
Code: 11(1
00 Contractor's imp's Lie then Law docs not apply tct an owner of property who ALTER-DRAIN&VENT-WATER(EM
Wilds or Improve thereon,and who contracts for such pUojeas with a
ciptlactor(s)Hoemed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B& P C for this reasonOUTSIDE FEES
DRAINS FLOOR'ROOF,AREA,COND. SANITARY Y_ N_
Owner Dace RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURE?PER l.ftAP SCI IDOL TAX Y_ N_
I hereby affirm that I have•certlfiate of cons.to self-inure,w a RECEIPT N
certificate^!Workepri�C�omppensation Insurance ora certified copy thera.f&c. GAS EA.5YSTEM-1 INCAOUILEfS PARK FEE Y N
pgfi lab C3►d/ '?_-09 —
REI N
Policy N ECan� rr
cu GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
.m
r—lCepildied copy b hereby famished. GREASE/NDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ertitied copy l9 tiled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei t#
Qhis sn n
ectioeed not W completed It the permit b taro.hundred dollars rn
($100)orless3 WATER HEATER W/VENT/ELECTR SV ENERGY PEE Y_ N_
I certify that N the performance of the work forwhkh this permit b hath,
1 dull not employ any person any manner m n to bca
eme subject lathe WATER SYSTEM/TREATING
Worken'Compensatbn Tawe off CalBomla.Date PAID
C) Z Applicant NEWRESIDENTIALPLms. SQFT. Date Remi t#
Z O ,NOTICE TO APPLICANT:If,after making this Cartifiamof Exemption,you
should became subject to the Workers'Compensation pmvhiom of the Labor TOTAL:
CN Code,you most forthwith comply with such provision or this permitshallbe BUILDING FEE
W E3 deemed
w CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there h a constrocion lendingagency forthe perform- [ELECTRIC FEE
D Z am of the work for which this permit h issued(Sec.3097,Civ.G TOTAL: \.7
02 Lender's Name PLUMBING FEE ?!
H Landcr'.Addross QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 metifythat I havemad this application and statethatthe above information
a bmrrect.Iagree to comply with all city and county ordinance and pate laws PERMTTLSSUANCE FEES PAID
} relating tobutiding construction,and herchyauthmizercpresentativeactfthis
r N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save indemnify an it keep harmless the City of Cupertino Date Receipt#
V .Rant llaylties,)adgme.s,cops and expenses which may in anyway ce a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalnt ee(( 1 In ronsequemr gr g thio pertnit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signal e.(Applicant/ antrsRor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RDOUg MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the —"--
Health and Safety Care Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: a7
❑ Ya M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN ISINCLE RESID) ISSUANCE DATE
which emit hiumidom air contaminants as defined by the Bay Area Air ®
Do ality Ma nagemcnt District? BOILER-COMP(3191 OR 100,000 BTU!) P
4Y,-va —1 No
have read the hazy ous materials rcquiremenro under Clupter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Section 2550.5,25533 and 25534. I APR � ' 199
understand that if the building does not currently have a tenant.that it h my NEW REST DENTIAL MECH. SQ.FT.
responsibility,to notify the occupant of the requirements which most be met
prior to issmnce of a Certificate of Ocm panty. CITY tit VyTL.r%II
Owner or authoriud agent Date ISSUED BY_��
TOTAL:
OFFICE COPY