19898 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro act Identification PERMIT NO.
Building Add am:
y, �� ,w� 19898
r.r Phone: A
a 'J� eeCITY OF CUPERTINO-BUILDING DIVISION ^�
C rector' Na Lie.N. APPLICATION /PERMIT
U `" Q BUILDING-ELECTPdCAGMUMBINC-MECHANICAL CATEGORY CONTROL It
Archlteci/Engineer: Lre.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affbm that l am licensed under provision,of Chapter 9(comanarx, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)m Division ofthe Business and ProfeaelonsCode,and m
Iicense Istria to y�d effect PANELS
S
Ll msc Gla C.. Lit.N
Da Comra or /yJ ���m I�Q /Qy�
ARCHITECTS DECLARATION / 701-1000 AMPS
rcO Zp I understand my phns shall be used as pubic records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ff.
Fi f u Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIiCUIT/M15C
71-, IherehyafRrenthat Iam exempt fromthe Contractors License law for the
pp pp (olowing reason.(Section71D1S,Business and Professions Code:Any city or
FZ W county which requires a permit to mwruct,alter,Improve,demolish,or repair TEMP.METER OR POLE INST.
g� anystroctom pdorto its Wuance,also requlrestheapplcantfor such permitto POWER DEVICES
PJ file a signed statement that he Is licensed pursuant to the provislmu of the -
Q63µIE.. Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
sion 3 ofthe Business and PmfemkmsCode)orthat hob eaempitherefromand VALUATION
a.•37 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLE.ISSWETCHESF7%T.URFS /` 10(/d
O mpplcantfarm permit subjectsthe applicant to a civil penalty of not more than
(Iv hundred dollars(WO).
I,as owner of the property, NEW RESIDENTIAL ELECIRSQFf. STORIES TYPE CONSTRUCTION
�n p perry,or my employees with wages act there sole
a compensation,Busio the ness
and kand the s Code:TIs he
ow Conttended or License d for
Law
q ease(Sec.apply
to an o.and Professions Code:The or improve,License Law !
�$ doss notapply torn owner of properthrong his obuilds nemoy,.,provided that much
OCC.GROUP RES.UNITS
who doementsamnuch work untelf or nded or
ughed ow le.If, owe provided ilding h
Improvements arc not Intended oro(lered forsale.I[however,Ihebulldingor TOT
Improvement bsoldwithln one yearnfcompletion,theo amr-builderwill have
1 rden of proving that did not build or Improve for purpose ofule.). QTY, PLUMBI E IT E FLOOD ZONE APN
UM I,as owner of the property,am exclusively contracting with licensed MANCE
rontrxc ors to construct the project(Sec.7094 Business ami Professions Code: PERP
The Contractors License Law does not apply to an owner of property who D WA
builds or Improve thereon,and who contracts for ouch pNje�with a AyljR. FEE SUMMARY
cff;ctar(s)Ilmnsed pursuant to the Contractor's License Law. B WPRO 7.D CE
" "U I am exempt under Sec. B k P C for this reason
DRAINS. SANITARY Y N
Owner;
Data _ RPLEIIN
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y_ N_
q It
01
hereby affirm that I have a certificate of consent msol!-insure,ora RECEIPT N
corUOcate ofWorkers'Comperuation Insurance oramrtlfied copythemof(Sac. G -11NC.4 UILETS PARK FEE Y N
RECEIPT N
Com anvc ( GAS IA. SITIM-0VERd(EA) BUILDING DIVISION FEES
Certified copy is herebythMshed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM F.A.Hgb-T Date RCC(`i tet
(TNsseRlon need not bacompleted tithe permit le forone hundred dollars
m00)orleas) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mrtifytm
hat lath.per(ounceof the work forwhich thls permit is lemued, L I shall not employ any person In any manner so u to became subject to the WATER SYSTEM/TREATING
Workers Compensationlawsof Cailfumb.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQFr. Date Revel t#
O NO EICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you at forthwith mm ply permitsh
with much provisions or this permit all he I
LDING
I W
> deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyaffirmthettheeers.. rumors lending agenry(or the perform- - ELECTRIC FEE
7 Z 'anceof the work for which this permit is iseued(Sec.3097,Civ.C.) -TOTAL:
V O I.Mees Name PLUMBING FEE
U. I— Lenders Address QTY.I MECHANICAL PERMIT FEE MECHANICALFEE
Imrtlfy thatl have read this appllcztionand statethattheabovma
e Information
O W
1 lecorrect.Idgree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID.
>. N relating to building construction,and hereby authorize representatives a(this
j. city to enter upon the above-mentlonsd property lar Inspection purposes. ALTER OR ADD TO MECH.
? Me)agree to save,indemnify an d keep harmless the City of Cu ped Ino - Date Revel t#
L.1 agalnstlfabBltimajadgmemacmdsandex e"'a which may In anywayaceme AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
a�aid City In ronuquen sof gr ntin fthis It.
AIR HANDLING UNIT(OVER 10,0DO CFM) CONSTRUCTION TAX
Si ureof Appllam Contractor .Date E%HAU51'HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS ERIALS DISCLOSURE
Wllltheapplcantorfttumb ding occupant store or handle hazardous HEATING UNIT(TO 100,OOD BTU) Date Revel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and Safety Code I 2(a)7 HEATING UNIT(OVER 100,000 BTI!) TOTAL: Q
❑Yrs o
Wlllthe applicent or tore building occupant use equipment or devices VENTILATION PAN(SINGLE BIRD) 1$$I®AIQPYIATE
which emit hazardous air contamiunts as defined by the Bay Area Air I�..i'��
Quality Management Dl Hat - BOILER-COMP DEEP OR 100,000 BTUs
YvsI two
read the haze ous materials requirements under Chapter6,95 of BOILER.COMP(OVER 100,000 BTU) IIIH•`( r.: 01990
the California Health&Safety Code,Sections 75505,75533 and 2S539.1 ,
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
res raibility to notify pant of the requirements which moat be rrrt ,yy',1uVm
to Issuance hit f parry.
• /r/va� zo of o ��-a,� ay �{.., U.a�
n rorauthorizrd en[ Date - ISSUED BY.Vy'W—U'1e.-a`aa -C�
TOTAL:
'. OFFICE COPY