23522 APPLICANT TO FILL IN INFORMATION WITIOIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification r, PERN9TNO. 3 5
Building Address: � r ArIF� Z
1 0750 a wLou1� 1251 rlJ 23522
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neve aces: one:
CITY OF CUPERTINO-BUILDING DIVISION /[ !`t^y
Mfadmrs Names Llt _No; APPLICATION /PERMIT T /
Architect/Engimer. Llc.No: BUILDING-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL N W
r - QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addicas:' PERMITISSUANCE NZ ❑ O ❑ .
LICENSED CONTRACTOR'S DECLARATION
Thereby affmn that l son licensed under provisions ofChapwr9(commene APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwllh Section 7003)ofDlvlslon3ofthe Busies mdPmfe m.Code,andmy
.license b In full torn and effect. PANELS ...���...///........
LicenseChnItN
L
Date Cic.11 r -
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�uu ce0 2 I understand my pWm shag be used m public records. OVER IOW AMPS SQ.FT.FLOOR AREA S/SQ.FT.
biU
Licensed Professional SIGNS ELECTRICAL' a
OWNER-BUILDER DECLARATION
71o., Thereby af0rm SPFLIALCIRCUIT/Mi9c
that am exempt frornlhe Commei6es License Law for the
O L following...(Seaton 70315,Business and Pre(eslo is Code:Any city or TEMP.METER
countywhichrequiresa permlttommimcMalter,impmve,demabh,ornpair
anyatmdurepriortolfslsuaner,alsorequirntheappUo t(orauch permit to POWER DEWCES
file a signed statement that he V licensed pursuant to the provisions of the
Confadoes License Law30� comm
ha erg endn with Section 7000 of Divi.
sion3oflhe Businneand Profma mCode)orthaheieemm themfmmand MI
SWIMNG POOL ELECTRIC VALUATIONO�
f. Q:ithe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS—SWITCHES-FIXTURES
one.
appllcantfora permit subjects the applicant to a civil penalty of not than
tlundred dollars($SOO). NEW RESIDENTIAL ELECIR SQ.Ff, STORIES TYPE CONSTRICTION
�n 61,as owner
of the property,or my employees with wages as their sole
compensation,will clothe work,and the structure Is not intended or offered for
O sale(Sec.70U,Buslmes and Profenloru Code:The Contractors License law
3$ doesnolapply toan owner of pmpenywho builds or lmprovesthereon,and OCCGROIII' RFS.UNIT'S
who doessuchworkhimselorthrough Nsownemployees,provided that such
Improvements are not Intended or offered for sale.If,however,the build ing or TOTAL:
improvement is sold within one yearofcompielion,the owner-builderwill have
ti,ttlurden of proving that he dm not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U L ae at of the property,am exclusively mntranlng wghI—.— PERMIT ISSUANCE
contractors to construct the project(Set 70K Business and Protenions Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN k VENT-WATER EEA)
or Improves thereon, and who contracts fee such ptlojecta with a
cgg((ador(s)licensed pursuant to the Contractors License Law. gAQ(pLOW PROTECT.DEVICE FEE SUMMARY
L.�I am exempt under&a B 4+P C tar this remoraFEES
Owner Date DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N
LWORKMAN COMPENSATION DECLARATION RFOEfPI'N
Ell hereby affirm that I have•oenifiate of consent to self-Insure,or a FIXTURES PER TRAP SCHOOL TAX Y N
nalBatem(Workers'Compensetlmn Insurann ora nrtlfkd copy tM1ereaf(Sac. RECEIVE N
3800,Lab CJ GAS P.A.SYSTEM-11NCAOVILETS PARKFEE Y N_
Pa11q N GAS FA.SYSITMAVER a(EA) RECEIVE N
Com ray BUILDING DIVISION FEES
dCedlfied copy is hereby tthcity
e city inspection division.e
d.
�CedlRed copy V filed withh the GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE /
CERTIFICATE OF F7(EMPTION FROM WORKERS' GREASE TRAP PAID ��
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2EUFT. Date RCCCI t#
(This section need nor be completed if the permit b for one hundred dollars
ESI 00)or leex.)laseO WATER HEATER W/VENT/ELECTH ENERGY FEE Y N
I certt in the pedomunm o(the work(orwhich this permit is lseued, —
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
orken'Compensation Lawsmf GBfornia.Date PAID
PP sQFc Date Remi
Z �
and NOTICE TO APPLICANT.U,after rking this Certificate of Exemption,you NEW RESIDENTIAL PLMB.
m
should become subject fo the Wmrkers'Compensation provhbmoflhe Labor VOTAt
N
Code,you=at forthwith comply whhsuch provlalons orthis permit shall be BUILDING
W j deemed revoked. -
LU - CONSTRUCTION LENDING AGENCY SEISMIC FE
I hereby af@m that there is a mrutmcilon lending agency for the perform, ELECTRIC
Z ante of the work for whkMfMb permit le Issued(Bee.3097,Civ.CJ TOTAL: TReipt#O ' lenders Name' PLUMBILL F Lender'.Address QTY. • MECHANICAL.PERMIT PEE MEC N OW Icedlfyfhatlhave..dthbappllallonandeatethaffheabovainformmimnaiscormet.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEESPcity to enter upon the above-metionsd pmperty for Wpection purposes, ALTER OR ADD R7 MECH. Date
— (We)agre ve,indemnify and keep harmless the Clty of Cu pertino
aga0uth t ,jud n cost expenseawhlchmgln Y.A... AIR HANDLING UNIT(TO 10,000 CFM)
g.;B In a he fpaptTpltatL}Me perm] SUBT AL:
AIR ltAhrouNc UNIT(OVER la,000cFM) CONSTRUCTION TAX
gmtu o(A o /Contractor EX
ate — HAUIC
STHOOD(W/DT) CONSTRUCTION TAX P ID:
N RDOUSMATERIALS DISCLOSURE
W the liant or future building occupant store or Its ad Is hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material ae defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Ilea�lt hand Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
TVil the applicant o otme building occupant use equipment or devices VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air cents mlmnta as de0ned by the Bay Area Air
Quality Maragement Durld7 BOILER-COMP OE I'OR 100,IX0 BTU) fA p
A
❑, •a YNo B' B
Diavercadlhehazaousrrulerlaisrequimm nmunderChapler G95of IOILFRCOMP(OVER 100,000 BTLI)
the Calltomia Health&Safety Code,Sections 25505,2:533 and 25534. IJU
/ L
understand that if the build ing don not currently have a hlctenant,that it is my NEW RFSIDENTBAL MECH. SQFT 9z
responsibility to notify the occupant of the requirerrentewh mus be m �9
at / (r
prior to Issuance ata Certificate of Occupancy.
CITY OF CUrrn f uvL
Owner or authorized agent - Data ISSUED B
TOTAL:
OFFICE COPY