23304 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proet Identification 7 PETLWT NO.
Building Add mss: 774 ,—rE51/ oA 10A 23304
woes nton
ae: e: APPLIUAIIVIN bUD.Mll JALA
994-16V() CITY OF CUPERTINO-BUILDING DIVISION
. can a .Name: r 2a� (�Ir.Ne: ^ APPLICATION /PERMIT
a s✓� / 7�a BUILDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Llc.No:
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 1� E:1 El ❑
LICENSED CONTRACTOR'S DECLARATION
IMrcby affirmthat l am licensed under provisions of Chapw19(commenc APPLIANCES-RESIDENTIAL JOB DESCRIVI'ION
ingwith Section 7000).(Dtv1sion3ofthe Buelnessand PmfesslonsCode,and my
license Is In full force and effect PANELS
Llccnsc lames_�(j_Lk.N b a
Date ���4 Contra_nay-y�—
ARCNITECTSDE LARATION 201-IW0AMPS
esZ I understand my plans shall be used m public records. OVER I"AMPS SQ.FT.FLOOR ARRA 5/9Q.FT.
O
u� Licensed Professional 9GN5 ELECTRICAL �pI� ^p q se�`�
Q w OWNER-BUILDER DECLARATION �I O V A L E 'L✓' 8 11 �]
fn�uZ SPECIALCIRCUIT/MISC
Fp. I hercbyafOrnthat lamexempt from the Contractor's License Law forthe
O Z t, following reason.(Section 70315,Business and ProfessionsCode:Any city or TEMP.ME EIR OR POLE INST.
p county which requlresa permit to construct,alterjonprove,deniolbh,or repair t1r�
V u
B
Ky J j anystrumrrc prior to its sucance,abr,requlmathe applicant for such permit to pOWEg DEVICES [,
C U file a signed statement that he is licensed pursuant to the provisions of the j T
3 nATr
Contractors License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC A ON
O sion3oflhe Business and ProfessionsCode)orthat he lit exam therefromand
6 the basis for the alleged exemption. Any violation of Sections 70315 by any OUTLETS SWITCHESFIXTURES --_
applicant for a permit subjects the applicant to a civil penalty of not more than
p. five hundred dollars(SSOO). NEWRESIDENTIALELFCTR SQ.FT.
.. F1 I,as owner of the property,or my employees with wages as their sale STORIES TYPE CONSIRIICTIOA'
pen.atlon,wi ldo the work and thestructure E not intended or offered for
Sa p sale(Sce.7056,Business and Professions Code:The ContraRols License law
psi does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROfITa RES.UNITS
G who doessuch work himself orthrough his own employees,provided that such
improvements arc not Intended oroffered forsals.If,however,thebuilding or
Improvement esold wilhinoneycarofcompleMbgtheowner-W ederwill have
tF19jxvden of proving that he did not build or improve for purpose ofeals.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contract..to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does But apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
sued,.r improves there.., and who contracts car such piuscus with a FEE SUMMARY
y�t[[actor(s)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
cc
L)I am exempt under Sec. B &P C for this reasonOUTSIDE FEES
Owner Dale DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N—
•
RECEB'TN
WORKMANCOMPENSATaONDCLARATION FaTDREs PER TRAP SCHOOLTAX
❑I hereby affirm that I have a certificate of consent to self-Instro ora RECEIPT N
certificate of Workers Compensation Insurance or a certified copy thereof(See. GAS EA.9YSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab Q —
Policy p RECEIPTN
GAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISION(GES
Cam any
�CeNBed copy Is hereby tthe cid.
rteGREASE/WDUSCRL WASTE INTERCEPTOR PLANCHECKFEE
ied copy V filed with
the city Inspection division.e CERTIFICATE OF"EMPFION FROM WORKERS' GAEASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MET Date Recd t#
(This section need net be completed if the permit is for one hundred dollars
(510erslem.) WATER IiEATQt W/VENT/F7,FCTR ENERGY FEE Y_ N_
I certify that U the performance of the work for which this permit is Issued,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TRFATING
Workers Compensation Laws of Cab(mnu. Date PAI D
O Applicant Date RCCCI Ik
Z NEW RESIDENTIAL PLMB. SQFT.
Z O NOTICE TOAsubjed to
aNerars'Co passatimp o is Exemption,you
F N should bec.me�subject to the Worken'Compevatlon provisions of the Labor TOTAL:
� n Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
Ill — CONSTRUCTION LENDING AGENCY SEISMIC FEE
11 Ihereby affirmthat there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
n Z anco of the work for which this permit is pwed(5ee 3097,Civ.C.) PLUMBING FEE
I) lender's Name
O
LL F Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certifythatl have read thlsapptiratlonand statethat theabove lnformati.n
(1 nommct.l agnesto comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER ORADDTO MECH.
(We)agree to save,Indemnify an d keep harmless the City of Cu peril.. Date Receipt#
V against lUblBlies,judgments,costs and ex peones which may In any way&=me AIR HANDLING UNIT(TO 10,0DO CFM) SUBTOTAL:
against said City in consequence of the grant mg of this permit. CONSTRUCTION TAX
AIR HANDLING TINCT(OVER 10,000CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appliesrat orfuture building occupant store or hand le hazardous HEATING UNIT CFO 100,ODO BTU) Date Reuel tM
material as defined by the Cupertino Municipal Code Chapter 9.12,and the
I lealth and Safety Code xaSort'ion 25532(a)P HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes �Vo
dr
Will the applicant fiamre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air eontaMvnts as defined by the Bay Area Air
• lay Management District? BOILER-COMP QHP OR 100,000 BTU)
Yrs No
shave read the h.ra m materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BT U) P A V D
the California Health&Safety Code,Sections 25505,25533 and 2534. I
understand that if the building does nes currently have a tenant thatltkmy NEW RESIDENTIAL MECIL SQ.FT. Q 9y
rmponsibilityto notify the occupant of the requlrcments whic st met APR d� 199!''
Priors 'muance o(a Cen 'ate of Ocmpa rya
Owner or authorize agent to T s ISSIIEdIBY t l , t 1
OFFICE COPY