20742 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: f"1 O
o W .t v G ,742
ners ante: one:
U tE CITY OF CUPERTINO-BUILDING DIVISION
• GontaaoraNa ,/I Lie.No: APPLICATION /PERMIT
c_ Y BUILDING-ELECnUCALPLUMBINGMECF LAICAL CATEGORY CONTROL a
rchnea/Engf.er, Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMETISSUANCE �_�� ❑ FUn ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prewislo s of Chapter 9(commere APPUANCESRESIDENTTAL JOB DESCRBTION
Ingwith Section 7000)of DiAMon3oftheguslnemand ProtessionsCodgand my
It...b in fuB(o and effect PANELS
License LIC# ID
Date•/� ContnRor
ARCHITECT'S DECLARATION 201-1000 AMPS
9z I understand my plans shall W used as public records OVER1000AMPS SQ.IT.FLOOR AREA $/SQ.FT.
zpOp
O Licensed Professional t SIGNS ELECTRICAL 6, Dy
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M19C
Iherebyaffirmthat l am exempt fromthe Contractor's License Law for the
.Fgt- following Mason.(Sectlon 70315,Business and Profeadons Code:My city or TEMP.MMTR OR POLE INST.
mmtywhich mqulmapemutroco.tract,alteq improve,demolbh,orrepalr
any structure prior to its L uance,alsorequlresthe applicant for such permit to POWER DEVICES
O o. file a signed statement that he in licensed pursuant to the provblom of the 1
3a Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING POOL ELECTRIC. VALUATION
sion3ofthe Buslnessand Profewiom Code)orthatheisexemptthemfmmand
G5p1 �d the basis for the alleged exemption. Any violation of Section 7e31.5 by any44 OUTLE7SSWITCFIFS ES 3
6X applicant for a permit subjects the applicant to a civil penalty of not more than 6"
r. five hundred dollars($5500).
'4• 1,as owner of the property, NEW RESIDENTIAL EL SQFf. STORIES TYPECONSTRUCTION
.- ❑ p ork,a er my employee with wages r thele sole
k7Q compemation,wBldotW work and the atmcturcbrrot Intended or offered for ,
Sa ❑ sale(Sec.70"Btulor.and Po fesslo.Code:The Contractors License law
psi does not apply to an owner of property who builds or improves thereon,and OCG GROUT' RIS.UNITS
who does such work himself or through his own employees,provided that such
Improvements arc not intended muttered forests.I(,however,thebuildingor TOTAL: _D
improvement esold within oneyearofcompletlon,the owner-bullderwlll have
to rden of proving that W did noWild d or improve fou purpose of sale.). QTY, PLUMBIN E MI FEE
UI,as owner of the property,am exclusively contracting with licensed FTADD ZONE APN
PISSUANCE
contractors to construct the project(See 70K Business and Professb.Code:
The Contractors License law does not apply to an owner of property who
Wilds or Improves thereon,and who contracts for such p(ojects with a AL IN& - A t
c,,ttLLtT[actor(a)licensed pursuant to the Contractors License Law. BACK PRO .DrEVICE \ FEE SUMMARY
LII am exempt under Sec. B&P C for this reason �_ OUTSIDE FEES
DRAINS R •,A SANITARY Y N_
• Owner Data RECEIPT#
WORKMAN COMPENSATION DECLARATION ITXTl1RES SCHOOL TAX Y N
❑I hereby affirm that 1 have a certificate of consent to self-insure,oraRECEIPT M
certificate of Workers'Compensation lmnm
unaramnified cepythenrof(Sec. GAS EA.SY -1 WCAO PARK FEE Y N
3800,Lab C.) RECTIPT
Policy N GAS EASY AVER (EA)
Company BUILDING DIVISION FEES
❑
if
copybhereby furnished. GREASE/INDUSTRL WA EPTO PLANCHECKFEE
edified copy b flied with the city Isspe to n divialen.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA.I!00FT. Date Recei tN
(Thbxction need not be completed if the pemdt hfor e.hundred dollars
($100)mless3 WATER HEATER W/VENT/F7.ECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhich this permit Is blued,
1 shall not employ any person In any manner se,as to become subject to the WATER SYSTEM/TREATING
Workere'Compewtlon Gwso(Gllfornia.Date PAID
O Z Applicant NEWRESIDE TIALPLMB. SQ.Fr. Date Reoci tit
Z O NOTICETO APPLICANT.]LaNer makingthhccdift.tx.f Exemption,you
should become subj^d m the Wmken Compe.atton provide.of the L.Wr TOTAL:
!2 Cede,you most forthwith complywith such provisiona orthb permit shall be BUILDING FEE
W j decr d revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
11 Iherebya(firmthatthem isaconatmctionlending agency for the perform TOTAL:
ELECTRIC FEE
Z ance of the work for which this permit b Issued(Sec.3097,Civ.CJ
U O I<ndcre Name PLUMBING FEE
LL I— Lender's Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
U IcertRythatl have read this application and statethatthe above Information
O W incurred.I agree to comply with all city and county ordinances and state laws PERMITLSSUANCE FEES PAID:
0. relating to building co.trudlon,and herebyauthortmesprexntativesofthis
(A citymards'upon tWabav'rrantioned propsnyfmimpool.n purposes. ALTER OR ADD TO MUCH.
Z (We)agree to save01nd /d,7psh:rm`(,xs te City of Cupertino Date Reeeiplil
g.-Ibis' t ,pdgnwhichmayleanywayaccrue AIR HANDLING UNIT(TO 10,W0 CFM) SUBTOTAL:
agai. Ity <oting oftNs permit.
AIR HANDUNG UNIT(OVER 10,0DOCF'M) CONSTRUCTION TAX
Signature of App lean nor at EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA tDOUS MATERIALSDISCLOSUR
Willtheapplem rfuture building occupantstore orhandle haaardous HEATING UNIT CIO IOg0D0 BIID Date Recel tk
material as de0red by the Cupertino Municipal Code,Chapter 9.1 7,and the
I lealth
❑Yand Safety Code,Section 2S532(a)? HEATING UNIT(OVER IM,000 BTU) TOTAL:
N.
Willthe applicant or❑future Wilding occupant meequlpment ordevices VENTILATION FAN(SINGLE RESID) IDATE
which emit hazardous air contaminants as defined by the Bay Area Air a
Quality Management District? MOILER-COMP(UIP OR 1M,0())BTU)
Yes MN. q
have read the havoils materials requirements underChapter6.95 of BOILER-COMP(OVER I0LDD0 BTU) •4 H `` C,
the Califernia Health&Safety Code,Sectio.ISMS,21533 and 2553x.1
understand that if the building does not currently have a tenant,that it Lamy NEW RESIDENTIAL MECH. SQ.Fr.
rcvponsibility,to notify the occupant of the requirements which must W met yelps
prier to issuance of a Certificate of Occua,.y
at CU Ie„pancy. IRop
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY