24382 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NQ, 4 3 8 2
Building Addw: Z
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arePhone: APPLI�AIIUNSUBMIIIALUAM
• CITY OF CUPERTINO-BUILDING DIVISION U,
Contractor's Name .+ e. n: APPLICATION /PERMIT
BUILDINGM3 TMCAI.PLUMBING-MECHANICAL CATEGORY CONTROL
rchlt /Engltuer. L4'. o:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address
❑LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE L:1 1)q ❑
I herebyafm70lhatlamgcenxftImtuader Bupanc,annsof Cssions9(rommmc- APPLIANCES-RESIDENTIAL ]OB DESCRIPTION
Ingwithin fan force anDlNfect. theBudnessandlsrofesdonsCade,and my
]lanae is In full fora and effect. PANELS
Limn CCN
Date ContractorUP TO 200AMPS
ARCNITECI`B DECLARATION 711'1000 AMPS
00 lunderstend my plata shag be used ssm
public OVER 1000 AMPS SSQ.J]'. �A .FT.
Llmnxd Professional SIGNS ELECTRICAL /a��
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC 0;'� L. D
z. a Iherebya(Brm that]am exempt from the Contractor's License Taw for the
g following reason.(Section 70115,Business and Professions Code:An city r n �] P B p � e-.
F cauntywhlchrequlmapert wmmtvct,alter,bnpmve,demlWh,or pair TEMP.MUM ORIOLE INST. (Ivd `IIVp gL_. Fr
'�a anyatmu mpriortoltsk ance,al requlmtheappgantforsuchp.m tto
p POWER DEVICES
O 0. (Ilea actor's License
that het Banned nanism to the prowlon&7000) of the
3u�
Contractor's Licerue law(Chapter9(commencing with Section 7000)o(Divi-
SWIMMING POOL ELECTRIC
SOS sion3 ofthe Business and ProfesslonsCods)orthat he is exempt therefromand f
S° the basis for the alleged exemption. Any violation of Section 703IS by any
sppbesnt for a permdtsubjetsthe applicant to a civil penalty of nes more than OUTLEISSN77'CFIEr`A%TURES
Infive hundred dollars(5500). NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSI'RUCTION
❑I,as owner of the property,or my employees with wages as their sole
mmpereatlon,willdolhe work and thestructure is not Intended or offered for
sale(Sec.7044,Business and Profess]..Code:The Corm ctols Lt..law
�$ does not apply to an owner of property who bulbe or Improves t hermit and OCC.CROUP RES.UNITS
who donsuch work MmxRorthrough his own employees,provided that such
Improvements are not intended or offered fee sale.If,however,the building or TOTAL:
Improvement issold within one yearof compledon,the cwnmbullderw111 have
tIlLtlunden of proving that he did nm build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed FLOOD TONE APN
contractors to construct the project(Sm.704{,Bouinem and Prafesume Code: PERMITLSSUANCE
Tb c Contractor's Limme,Law does nes apply to an owner of property who ALTER-)RANI AVENT-WATER(EA)
builds or Improves thereon, and who contracts fee such pkujects with a FEE SUMMARY
=Aactor(s)licensed pursuant to the Contractor's Limmse Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B h P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y
Owner Date _ REC M
E31 here K
WORMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y N
by affirm that I have•certlBeste of consent to self-Insure,a a RECEIPT N
3800,ab of Workers Compevatlonlnsurenamaadified copy themof 6ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy
CJ _ RECEIPT#
C.
Y GAS F.A.SYSTEM-OVER 6(EA)Com any - BUILDING DIVISION FEES
MCedlRed copy is hereby furnished. GREASE/INDUS[RL WASTE INTERCEPTOR - PLANCHECK FEE
❑CeAllied copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' G TRAP PAID
COMPENSATION INSURANCE -EWER. ARY-STORM EA x1oF[ �' Dale RCCeI to
(Thlssectbn need not be completed if the permit isfaone hundred dollar
(5100)mfy that
-HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of ehework lorwmch this permit Is Issued,
I shag not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Wmkere'Compensation LawBof Cahfomb. Date PAID
OZ NOTICE` NEW RESIDENTIAL PLMB. SQFr. Date Remi tit
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Workers'Compersmlon provisions of the Labor TOTAL:
N Code,you most fon hwlth mm ply wlthsuch provisium or this permit shall be BUILDING
W > domed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaf0rmthat there is a mmtructlon lendlegageecy for the perform, ELECTRICFEE
M Z ance of the workfor which this permit to beued(Sce.3097,Civ.Q
V O Lcoder'sName PLUMBING FEE t
LLI— Lender'sAddrev QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I adBythatl have read lhisappliatlona Mdatethatthemoveirdmoru ion
CL Isoure tlagmlocomplywithallcityandcountyordlnanms.odstatelaws PERMIT ISSUANCE FEES PAID:
>. relating tobullding construction,and herebyamhorize representatives ofthhs
Zcity to enter upon the abownentioned property fee inspection purposes. ALTERORADDTOMECH. Dale Recd I
V (We)agreetosave,IndemNfyand kmpharmdessthe Cltyof Cupedlno AIR HANDLING UNIT CTD ID,WOGEM) P
agaWt Babllitln,jttlgmenb,cortsarm expenses which may in anywayacaue SUBTOTAL:
agai-A e d City In omesienced the ning this permit. p
IU 2- AIRHANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Ignature of App an Contractor Date EXHAUST HOOD(W/DUCECONSTRUCTION TAX PAID:
A7ARpOUS MATERIALS DISCLOSURE
Will the app ant or future building occupant store or handle hazardous HEATING UNIT(TO l 00,ODO BTU) OafC Recei A
material as defined by the Cupertim,Municipal Code,Chapter 9.1 7,and the
I❑alt and Safety Code Section 25537(a)? HEATING UNIT(OVER 100,000 BTU) _ TOTA �
Yee
Will the applies or aluture building occupant use equl pmenl or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q+ city Management District? BOILER-COMP UHP OR 100,0(0 BTU)
4 Yo No
have read the h azo ous materials requirement,under Chapter 6.95 of BOILER-CO.MP(OVER 100,00)BTU) RAI ® '
the G ifomia Health k Safety Code,Sections 25505,75533 and 2553/.I
understand that if the building don nm currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT
maponeib0ltyto notify the occupant of the requirements which must be met O2
prior to Issuance of a Certificate of Occupancy. ®� • 2 C
ISR
Owner or authorized agent Date
TOTAL: ISSUEDH�� )Y T5
OFFICE COPY