24312 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT N2 4 3 1 Z
Building Address;
n re one: APPLICALIUNbUBMI I LAL UA
_dIZ� CITY OF CUPERTINO-BUILDING DIVISION
G°^trat°' Lk.Np: APPLICATION / PERMIT
Z BUILDINGFI.ECTEUCAUPLUMBINGMECI IANICAL CATEGORY CONTROL It
Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am llcensed under provisions o(Chapter 9(mor menc APPLIANCESRESIDENTTAL JOB DECRNTION
ingwith Se ..70001of DiWsi.3.fthe Businoesand Professi.n,C°de,and my
Bcenee20sas is in force and c.9 PANELLlcer. S
`-
ficame Clam Ufec
Date Contractor !}
ARCHITECT'S DECLARATION 201-1000 AMPS
re0 7- ' I understand my plans shall be used as public records. OVER IMO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
µqqµ! O
E� Licensed Professional 57CNSELECTRICAL N t
Fcid 6 OWNER-BUILDER DECLARATION n II a�
a y SPFDIAL CIRCUIT/M15C Q r
Yl owing ason. that lamexem from the ConrofRooa License Law fart he L'� E
2p�� county which
mquimsa permittocoslnessand Professions Cod=:Anyttyor _ _�' ^
! �2. TEMP.METER DIPOLE INST. � f A,..[a
� cpuntywhkh rcqulresa permit tommtruct,alter,improve,demolish,orrcpalr i
g anystmctum priortolts Issuance,also requlreelheapplcant forsuch permit to POWER DEVICES
15 O1 file a signed statement that he Is licensed pursuant to the provisions of the
G613µ Contractor's License Law(Chapter9(comnlencingwith Setlon 7000)of INA-
GiOIn ston3 ofthelluslneasand ProfesslonsCode)orthat hole exempt therefromand SWIMMING POOL ELECTRIC
N
a-tt the basis for the alleged exemption. Any violation of Sect Ion 70315 by any OU7I,ETSSWITChIFSFI%TJRFS
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars(S900). NEW RESIDENTIAL ELECTR SQ.FT.
nI,as owner of the property,or my employees with wages as their sok STORIES TYPE CONS'LRUCTION
7a compensation,wWdo the work and thestructure h not intended or offered for
O sa1e(Sec.7044,Business and Peninsula.Code:The Contractors License Law
jQ does not apply to an owner of property who builds or improves thereon,and OCG GROUIs RFS.UNITS
whodoe suchwork himself orlhrough hisown employees,provided that such
improvements arc not Intended proffered forsale.If,hvwever,thebuilding or TOTAL-
Improvement
OTALimprovement leaold within one yearof completion,the owner-builderwill have
tFif,�erden of proving that he did not build or Improve for purpose ofeale.). QTY. PLUMBING PERMIT FEE -ffDoD DNE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094.Business and Preforslors Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(FA)
builds or Improve.thereon, and who contracts (or such En jeab with a
�'gRl�ator(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See. B k P C for this reason
HS
OwnerDRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
Date RECE Na
WOR KMAN COMPENSATION DECLARATION FIXTURES PER IRM SCfi00L TA%' Y N
hereby affirm that I have a cemftcate of consent to eel(-Insure,or a RECEIPT M
nl( eofWorkem'Compeesation Insurance or a certlfkd copy thereof(Sec. CAS EA. INCA 3800,Lab CI PARK FFR Y N
Polity a_00EV�S•IC7 GAS EA.SYSTQd.OVFR d(EA) RECEIPT R
Com anv _Mx BUILDING DIVISION FEES
Certifed copy 6 hereby tumecity GREASE/INOUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy V filed with the tlty Ivpectlon divlelon.
` CERTIFICATE OF FXEMPFION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM IIA.200FT. Date Repel t#
(TMssedion need not be completed Bibs permit is for case hundred dollars
(El00)orless.) WATER HEpTE(W/VENT/E.E.TR ENERGY FEE Y N
Icomfy that Int he person
of thework so as to blhlseesmlHc issued,
I shall not employ any pees°. f any manner m u to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of Glifornh.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFf. Date Recei t#
Z O NOTICETO APPLICANT:I,after making thh Certificat,.(Exemption,you
should become subject to the Workers-Compematlon provisions of the Labor TOTAL:
Vl Code,you..t forthwith comply wlthsuch provisions.,this pmmitahallba 6U TNG
deemed revoked.
ILO CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyalil that there is a construction lendingagency farthe perform. ELECTRIC FEE
Z ante oflheworkforwhlchthls permit B issued CF.3097,CIv.CJ TOTAL:
V O Lender's No , PLUMBING FEE
LL 1= Lender'sAddems Q7'Y. MECHANICAL PERMIT FG& MECHANICAL FEE �^^
O W Icenlfylhat l have mad this application and state that theab°velnformatlon
Is l agree to comply with all cityand county ordlnanmand gate laws 1 PERMIT ISSUANCE FEES PAID:
} a to at l ng to mtmcflm,and hereby authorlu representatives o(this
1-. N etytoe rupont above-me lmocipropertyforlmpenleopurp°ace. ALTER OR ADDTO MECH.
? (We agree to .vc,Inde tylan d keep harmiem the City of Cupertino PAID
ReCei t#
O agalrot Bal�llt ,judgmenro oe.O..d expense,which may In acy..yt.e AIR HANDLING UNIT(TO 10,00D CFM) SUBTOTAL•
against v.1 Ity In cp n of the granting o(thb pemdt.
9r� AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCFIONTAX
Signatuto of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplirantorfuture building occupant store or handle hamrdous ' FI'ATINGUMT(TO100,000 BTU) S' s
matedal as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Revel t#
Health and Safety Code Section 2SS32(a)? HEATING UNIT(OVER 100,000 BTII) TO
❑ Yea NN.
Will the applicant cefewre building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit havardou,air contaminants a,dented by the Bay Area At,
Quality Mawgement District? BOILER-COMP OHPOR 100,000 BTU)
theq Yes n Na BI?��
have read teeth& et mode,Le tions 2rrcnbunderChapte4.I of BOILER-COMP(OVER 100,000 BTU) Ir
understand
California Helithe alth building
Code, ocurrentlyh have
a 3 and tenant,
that
usponsind that notify
the occupant
note currently haves tenant that be Is my
NEW RESIDENTIAL M(EC}i. SQ.FE OCT
responsibility of Certificate
of Oc( parcy.ircmenlswhich must be sect @ I9pq
prior to Issuance ofaCertificate of Occupancy. (/ I .
C11
Owner or authorlaed agent Date ;,s-1 ISSUED By:
OFFICE COPY