23094 (2) APPLICANT TO FILL IN INFORMATION WITHIN'RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 123094.
n rsL a Ca.� CITY OF CUPERTINO-BUILDING DIVISION _ 1,- -2 I
Carrier J. ,�°: APPLICATION I PERMIT' `
BUILDINGELECTRICALPEdMBINGM HANICAL CATEGORY CONT) a�
Arc nett/Engineer. Lle No: (O L—
(�p / �1 w, QTY ELECTRIC PE FEE BUILDING PERMIT INFO
Address: 2 /1 d1 �1 ra,,r.YL Q 6L/' 'nz PERMITISSUANCEI'J �` ❑
LICENSED CONTRACTOR'S DECLARATION
]hereby affirnthat l am licensed under provisions of Chapter 9(examearne, APPLIANCESRESIK L 4 A JOBDFSCMP770N
ll=.11Sect1on7000)of Dlvlect. g1Buslnnsand ProfesslonsCode,and my ^ --
Ilcense le j.Z1 _ and effect 1^1 p? it PANELS
Date Contractor - V
ARCHITECTS DECLARATION
pkv%ZZIundemtandmyplaroshaBbeuwdaspubBc.c da 1 AM SQ.FT.FLOOR AREA $/SQ.FL
Licensed Professiotul ' SI 64SEL"
<�6 VESW OWNER-BUILDER DECLARATION IALC@C T LSC I�� Y
zp, 7� Ihereby afRreathe l.....pt from the Contradorb I I"rWLawforthe
following reason.(Section 7031S,Business and Professions Code:An cior
rs'u9 cwntywhichrequiresaperrrdtWmmtmdL ter,impmve,de=lbh,orrepalr TEMPMETLR ORPO INSF.
any stmetum prior to its Issuance,also requ ines the appllmnt for such permit to
Ofile a signed statement that he Is licensed pursuant to the provbion of the POWER DEVICES
Contractor's License Law(Chapter 9(commencing with Section 7000)ofDlvi-
�0 slon3oftheBusinessand ProfesslomCode)orthat bees exempt therefea d SWIdMING LELECTRIC VALUATION ,
O_ the baso for the alleged exemption, Any violation of naRbn 7031.5 a any ET SWITCHES-FIXTURES �e /, O
•rku? applicant for the permit exemption.
An vioatiin penalty of na morethan - Q
five undred dollars($500). NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
..�n �I,as owner of the property,or my employees with wages as their sole
'compensation,wBidothe work andthe structure Is not intended or offered for
O Male(Sec 7044,Business and Professions Code:The Contractors License Law
2 does not apply to an owner of property who builds or improves therron,and R
who does such work himselferthrough hlsown employees,provided that such O ,Y,
Improvements are not Intended motioned for sale.I(however,the building or ToRk VVV n,
improvement is add within one yearofcompletion,the owner-builderwlll have
tfr*rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE ^- DZONE
LJ L as owner of the property,am exclusively=trading with licensed PERMIT ISSUANCE
--trade.to construct the projed(Sec.7044,Business and Professions Code: M�
The Contractor's License Law does net apply to an owner M property who 7_7 -
builds or improves thereon,and who contracts for such projects with a ALTER-DRAIN&VENT-WATER(EA)
cffjcta r(s)licensed pursuant to the Contractors License Law. . FEE SUMMARY
�I I am exempt under Sec. B k P C for thin reason - BACK FLOW PROTECT.DEVICE OUTSIDEFEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Date RECEIPT p— .
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby AffirenmImr;that I have a Insuicaterance
of.comm to copy thereof
ora RECEIPT K
certificate of W°rken'Compeivatlan lruurance ora certl(kd ropythereo((Sec. CAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y N
3801 Lab CJ
Cc1iry M RECEIGAS EA.SYSTEM-OVER (EA) DING DT X
Com any BUILDING DIVISION FEES
�Certifiied copy is herebyth the citl. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
a�rledlRed copy ls filed with the city Inspection division.
��.•.. CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. - Date. Recei t#
(1hla section need not be complcted If the permit Is(ozone hundred dollars
($100),Ie..) WATER HEATER W/VEA/ELECTR ENERGY FEE Y N
I artily that in the performance of the work forwhich this permit is Issued,
I shag not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workere'Cmmpenaatlon LawsofC lhfrAnia.Date PAID
O Z Applicant - NEW RESIDENTIAL PLMB._9Q.FT. Date Recei t#
Z O hoaldbNOTICE TO esubjeAM:eWorr rs'Comoldinthis ation pro is Exemption,abo
� shwld become subject to the Workers'Comperuatlon provIsloru of the Labor IOTA '
IX W Code,you=at forthwith comply with such provisions or this permit shall be BUILDING
W > deemed revoked.
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
lherthe woirm'r whicat h
t i aronotmction ssued(Sec. agency 0W,Ciaor the perform- TOTAL: ELECTRIC FEE aa-•
7 Z anceofthe work(or which thio permitlsIssued(Sec,3097,CIv.CJ
V O Lender's Name PLUMBING FEE
IL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedifythatlhave m d1his.pplialk, d.datatethatthe abovelnformatlon
1 iscorrect.l agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE' �e FEES PAID:
>. 0. relating to building rorutmctlon,and herebyautheriu reprosentatives°(thls
I'_ U) citytoenterupon the above-mentioned property for Impaction purpose. ALTER OR ADDTO MECH. Date'- Receipt#
— (We)agree to save, ndemnity d p harMess the City of Cupertino
againstlWbill a,' o m de ossa which may in any wayaceme AIR HANDLING UNIT(1010,000 CFM) SUBTOTAL:
againstsa en o the .tin ofthmparmic AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signal of pplian/Contr dor I� Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store mr boodle hazardous HEATING UNIT(TO 100,"BTU) Date' Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safely Code Section 25532(a)2 HEATING UNIT(OVER IDQ000 SM TOTAL: 3
❑ Yes L_I No
Will the Applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)' ISSUAN�D,ATE
which emit hazardous air contaminants as defined by the Bay Area Air PpA, Uu
Quality Management District? BOILER-COMP OHP OR 100,"BTU)
:40
❑Yas No
]havereadthehaza�ous materials requirements under Chapter 6.95 of BOILER-CD.'NP(OVER 100.00097'()) ,��� �sy .�^^^
the California Health&Safety Code,Sections 25505,25533 and 25534.I ( 99Z
understand that tithe building don out currently have atenanp that it EA NEW RESIDENTIAL METH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met CI I r Ur CUF'�TI I NYU
prior to issuance of a Certificate of Occupa nry. V' ^� �. '''
Owner or authorized agent Date ISSUED BY`Y: ` �A �o- fAye _w
TO
OFFICE COPY