23785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES'— USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO. /�
Building Address: - of
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w e %, 6 Z 0 CITY OP CUPERTINQBUILDING DIVISION � L
>" ontrsdojsN �: Lie.No APPLPCAT ft / PERMIT
BUILDING-ELMTMCAL-PLUMBINGMECHAMCAL CATEGORY CONTROL X
Arc Iter/En neer. Lic.Nox -
.• ¢TY'• i s ELECTRIC PERMIT t ::FEC ``'' :BUILP!NG:PERMIT,INFQ `
Address: PERMITISSUANCE atr• ❑ ❑ -
LICENSED CONTRACTOR'S DECLARATION
ON
berebyafim,that l am licensed under provisions of Chaphr9(commenc- APPLIANCFSRESTDENTIAL JOB DESCRJPUCN
ingwithfiection 7000)ofaAgon3ofthe Businessand ProfesslonsCode,and my
license kin full rce and PANELS
LlceC ss Lt.N
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Date Contndor "" ✓ejYCLT IQ 20 AN25
ARCHITECTS DECLARATION 20I-10110AMP5
HOZ I understand my plans shall be used as public records. OVER 1000 AMPS I _ �Fl�7R AREA E/SQ.FP:
qqq� O Y/u
td 5 Licensed Professiarul SIGNS ELECTRICAL p�,-g
�6 OWNER-BUILDER DECLARATION SPECIALC1RCUIT/MISC
m :1 N/290 �
io.., Ihereby afBrtnthat l am exempt frothe Contrader's Lima.Law for the Moo
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Z E.' following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP METQ(ORPOLE INST.• v � '
t' countywhich requiresa permltto construct,alter,Improve,demolbh,orrepair
a nystmmmpdortoits Issuance,al mquimstheapplicantforsuchpermitto
S Cgfile a signed statement that he Is licensed pursuant to the provisions of the 706VER DEVICES
3,wfn
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUAT19�^_
O sion3,llhelusinessa,d Professlona Code)orthat he Is exempt therefromand (VJV
dthe basis for the alleged exemption. Any violation of Section 7031.5 by anynOUTLETSSWITCHESFIXTURFS 1 O O
O applicant for a permit subjectsthe applicant to a civil penalty of not ore than
live hundred dollars($500). NEW RESIDENTIAL ELECTR
I,as owner of the property,or my employees with wages as their sok �'bT' STORIES TYPE CONSTRUCTION
E]
compensation,will do the work and the structure Is not Intended or offered for
Osale(Sec.7044,Business and Professio®Code:The Contractors Lt..Law
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.[MRS
who doessuch work himself orthrough his own employees,provided that such
improvements are not intended orolferedforsale.If,however,thebuilding or T
i provement6soldwithinoneyearofcompldioMtheowner-bu0derwillhave
t rden of proving that he did not build or Improve for purpose orale.). QTY)'(•','.'Pt:UIMB(NG'PEIZMTTt ':�FEE'y FLOODZONE APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
.,ad..to construct the project(Sec.7014,Business and Professions Code:
The Contractors Ltrenss Law dare net apply to an owner of property,who ALTER-DRAIN&VENT-WATER BIA)
Wilds or improves thereon,and who contracts for such ptojed.witha -FEE SUMMARY
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aw
q➢_tfador(s)licensed pursuant to the Contractors License l , BACK FLOW PROTECT.DEVICE
u I am exempt under Sec. B &P C for this reason
Owner Date DRAINS FLOOR ROO$AREA,CO SANITARY Y_ N_ '
p'
WORKMAN COMPENSATION DECLARATIONFIX,IVRES PER TRAP X Y N_,
1 ❑I hereby affirm that I have a comfleate of consent to self-insure,ora RP
X
'certificateof Work m'Compeneation Insuranceoracertifiedmpythereof(Sec.
3800,Lab CJ GAS EA.SYSTEM-1 INCA OUTLET P Y N
p
Policy X GAS EA.SYSTEM-OVER 4(EA)
Com say - INC DI VI ION FEES
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Cartllled mpy6 hereby furnished. GREASE/INDUSIRL WAINTERC Rl - 'E
❑Cedi(ied copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP --- -^ - --
PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.700F1'. Date Reeel t#
(this section need not be completed if the permit 6(or one hundred dollars
($100)orlem.) WATER HEATER W/VENT/ELGCTR ENERGYFEE Y N
I certlfythat In the performance of thework forwhich this permit is issued, -
I shall not employ any person In any nunner so as to become subjed to the WATER SYSTEM/TREATING
Workera'Compensstion Lawa of Glitomla.Date PAID
O Z Applicant NEW RES DEN AL PLMB. SQF. Date Recei t#
Z O N'OTICETO APPLICANT:If,after making th6Certificateof Exemption,you
should bemene subject to the Workers'Compensation pmv"t of the Labor TOTA •
F.y Cade,you must forthwith comply with such provisions orth6 permit shall be -
W > deemd reke
evod.
W — CONSTRUCTION L¢vDlrvc AGENCY
FEE
cY SEISMIC FEE
11 therebyafillbut there is a constmctlon lending agency forthe perform ELECTRIC FEE JSO
D O ance ofthe workfor which this permit Is Issued(Sec.3097,CIv.Q - TOTAL
V Lenders Name PLUMBING FEE
F Lender's Address QTY: .:. MECHANICAL:PERMIT ^:;FEE%?
O W I certifythatl havereadthis application and statethatthe above information MECHANICAL FEE
IL is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building mrutrudion,and hereby authorize representatives of this
�.. W city to enter upon the above-mentioned property for Inspection purposes ALTER OR ADD TO MECH.
2 (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,costsand expenses which may In any way acerae AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
ago1N1 st—sold Cityleronaeque/nyeQhe granting of this peut
/T // AIR HANDLING UNIT(OVER Ig000CFM) CONSTRUCTION TAX
Signature of App
i " CONS RUCTION TAX PAID:
ntnt/Conrado EXHAUST HOOD
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicant or future building occupant store or handle hazardous HEATING UNIT(T0100,000 BTU) —DW t Recei t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I lealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
TOT
❑Yes M No ,
Will the applicant or future building .part a.equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE -
,., which emit harxrdous ale cents entrants as defined by the gay Arca Air -
Qa lityManagement DIstdct7 _ BORER-COMPO1E'OR100,000BTN
YdQ No4hveerSZOusmaterials requiremntsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU) n p
s
the California Health&Safety Code,Sections 25505.75533 and 25534.1•. 1," X'Y
understand that ifthe'building does can currently have a tenant,that it is my NEW RESIDENTIAL.MECH. SQ.hT
responsibility riortncoto n f a Cartecatsofoccupant of the requirements which must be met JUN
prior to Issuance ofaCertiBate o(Occvpancy. p'Ty�
Owner or authorlud agent
Data TOTAL: ISSIRO BY� .'`YhU7
ji
1 .
OFFICE COPY