19664 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building ProTed Identification PERMITNO,
1, Bullding4ddress:
yoRx sH�r� 19664
sonars ams: Phone: SUBMITTAL
S .�x'I rri GjFNG'F 2 CITY OFCUPERTINO-BUILDING DIVISION q
Contractor's Name: it Llic No: APPLICATION / PERMIT
130 F_RF MAS SRIft L Io� JO BUILDINGELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL M
Archited/Engiwer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ® El O ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prosWovof Chapter 9(mmmm APPLIAN MITHISIDENTAL JOB DESCRIPTION
ingwlth SecHon7000)ot DlWalan3o(the Buelneasandl'rvfneloneCode,and my
Iirense lc In full fa and affect. PANELS
License Ciaee('�r No
10 Q' C -„_
Data F4 G Contrador G ` {
ARCHITECTS DECLA ATION 2II-1000 AMPS
Kz (understand my plan shag be used upub0c rerorda. OVERIODOAMI9 SQ.FT.ET.00A AREA $/9Q.Fr.
OQ
y�y Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
np / I hereby afBrrothat l am exempt from the Contractors License lAw for the
following reason.(Section 7m1.5,Businm and Pro(mlane Code:Any dry or TEMP.METER OR TOLE INST.
Cr,F g mortywhlch requlresa permit to construct,alter,Improve,demolish,orrepair
anysimMmpdortoita Wuame aborequirestheappliantforsuchpermitto
POWER DEVICES
O� file a signed datemenl that he b licensed pursuant to the provbiav of the
u,1n Contractors License faw(Chapter 9(mmmencingwith Sedlon7000)o(Dist.��Op� ai.n3.fthe Budnm and ProfmiouCode)orthathei3exemptthemfmmand SWUIMING POOL ELECTRIC VALUATION
a�0 the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLE7SSWITCHF_SFI ES
Qapplicant for a permit subjectsthe applicant to a civil penalty of not month / 3 DTI
five hundred dollars($500). NEW RESIDENTIAL ELEC
'9..' ❑I,as owner of the property,or my employees with wages as their wee SQ STORIES TYPECONSTRUCTION
kandth
C Ci roIs&c. 0K w0ldotsand Prfiewho atrudurcla Conoended License Iforw
$ sale(Sec.apply
t oainv neer of property
who
build@The Condors theme law
3 dos notapply torn ownerorpropertywhobuildsorImprovesthereoryand OCC.GROUP RES.UNITS
who
ovementsa ntIntededorough hisowic.If,yev,providedthatsuch
Impmvementaarenotintendedo ro(co pldio thhmvevegthebulldingor
ve TOL;
Improvement Lasold withinoneycamfcomplMlon,theowner-bullderwBl haves
11W.Ilunden of proving that he did nest build or Improve for purpose ofule.). QTY. PLUMBING PERM FEE FLOODZONE APNr
Lj 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professlov Code:
The Contractor's Llmose law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptyjeds with a
cgp(CadoRs)Bmnaed pursuant to the C. os Lt...Law. BACK FLOW PROTECT.DEVICE
SUMMARY
I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y NOUTSID_
s , FLYS
Owner Date RECEIPT s
WORKMAN COMPENSATION DECLARATION
C31m
1 hereby affirm that I have a rtltioate of consent to self-Insure FIX'IVRF_S PER TRAP SCIdOOL TA% Y
,or a N_
certl(late of Workanx Compevatlan lvuranmora certified te,Nlfied cupytheof(Sec.
3800,Lab C.) GAS FA.51'SCFM-1 WC40UTLETS PARK FEEY N
Policy M RECEIPT M
Com an CAS-EA.SYSTEM-OVER A) BUILDING DIV]SION FE ITS
an
copy is hereby thcity
e city IvpMlon division.furnished.
CedOied ropy b(fled with
thCREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
AI
CERTIFICATE OF E%EMPfION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(rhissedion need not becompleted tithe permit laforone hundrcddollars SEWER SAM'fARY SRM EA.2001rr. Date ReceiptN
($100)orlyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
(codify thato the person nmofthework forwhkhco permitesubjec ho the —
7 Whale not employ any person In any manner at u to become subject to the WATERSYSTEM/TREATING
Workers'Compensation California.
llon laws o( Date PAID
0Z Applicant
Z O NOTICE TO APPLICANT:U,after making this Certificate,of Exemption,you NEW RESIDENTIAL PLMB. SQ.F. Date RecTelptill
should become subjed to the Workers'Compevatlon proallons a(the Labor TOTAL:
N Code,you must forthwith comply with such provldov or this permit shall be :73.
`apt
j deemed revoked. E
6W. G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z I herebydRrmthat there iso construction lendingagency(orthe perform- TOTAL: ELECTRIC FEE
(� O anm ofthe work forwNchthla permit is boued(Sm.3097,CIv.C.) PLUMBING FEE
Lender'sName
LL IT- Lender'sAddrcu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O U Imdlfythatl have read thisapplimtlnn and daethattheaboveinformation
fl bcormd.I agree to complywlth all city and county ordinances and orate laws PERMITISSUANCE FEES PAID:
>. W relatinglobulldingmvtmdion,and herebyauthodxerepremetativesofthb
H citywarter upon theabove-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z
V Z (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,Judgments,meta an expenses which may in anywayaceme AIR HANDLING UNIT(TO 10,0DOCEM) SUBTOTAL: .
a TZ IT
teal City In neeggegce oft gra ing o(Ihla pertnit.
(%LJ�
AIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
I
gig o3 fAppEant/Contradrn (Ate EXHAUST HOOD(W/DI1CT) CONSTRUCI70N TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant store or he rad ie hazardous HEATING UMT(TO 100,000 BTU) Date RCcei tN
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the -
Ilea lthaodSafety Code,,edlon 25532(a)? HEATING UNIT(OVER 100,000 BTU TOTAL:
Fj YesNo
Will theappilant Jr turebullding occvparduse equipment mdevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air n j
P,
{ Quality Management District? BOILER-COMP OHPOR 100,000 BTU !'k
aYes I�No
hyelmad the haze ous materials requimrrems under Chapter8.9S of B011,1211-COMP(OVER100,000 BTU)
'the Gli(ornls Health k Safety Code,Sections 25505,25533 and 15534.1 I - ;1 „f �j I
understand that if thebulldingdoes not cvrmotly have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FF.
onponsibillty to natty the occupant of the requirements which moat be met
prior to Issuance of a Certificate of Occupancy. cil-I n, "res^'1r11Dn
Owner or authorized agent Data I I ISSUEDBY: Tl�`— A'j Cc—I�
TOTAL: p—
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OFFICE COPY