22913 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PFYMT NO.
Build IngAddmas: 2 n GVyn 1 3
C1 1 068
ante: one:
Kra_ S QCT ZISA CITY OF CUPERTINO-BUILDING DIVISION 10�
Contractor's Name: r Lle.No: APPLICATION /PERMIT L TG
BUII.DINGELECTRICALPLIIMBING-MECHANICAL CATPfARY CONTROL# ti
Arc cert/Engineer. Lk N
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
I'EthBTISSUANCE E] ❑ W ❑
LICENSED CONTRACTOR'S DECLARATION PTIO
withSeI hereby affirm ion7Olhatlamlkmsedheunder BugrovWdPmf onsCocommm APPUANCESRESIDENML JOB DESCRIPTION
li natal'
ah l'fu 7000)afd eff.dn3o(thegutlnevmdPro(essionsCale,and my
Ilcon'A V N to o%[�� c# 5 PANELS yea yea �ix1
License Gla® Jb Llntl—y�
Date ContractorUP TO 2DO AMS
ARCHITECTS DECLARATI. 201-1000 AMPS
p�p�uu 9 COZ I understand my pla®.hall be used ea public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E z[3 Licensed Professional' SIGNS ELECTRICAL FINALED ' V A l
<<<uI
OWNER-BUILDER DECLARATION ,
F O, Y y ry SPECIAL CII2CUIT/MLSC T E
2 Ihereb aflrm/hat l am exemptfmm the Contractors License Law for the
fountywreason.(Section 7031.5,Business and Professions;Code:h, tl or
F� ir I1MP.METER OR POLE INS(.
county structure
requbes ior to s issuance,permit to conttm quires theA improve,demoibh,or mitrepto
4 afileny awduretatementhatheIalso requires nw,fiomor such of to POWER DEVICES
Ct Co a actor.statement that he b r 9(cont pursuant it ISe pmW tom of the
pQ� Ion 3 olthb License Lew(Cha lo9(mmmentln with Section7000)o!DlvlMA I
-
30G' alon3o(the BusineesmdProfmloru Code)orthaBhebeum therefromand SWIMMING POOL ELECTRIC VALUATION
6 the basis!or the alleged exemption. Any violation of Section 7031S by any OUT1ETSSWI7'CHFSFIXIURES
applicant fora permit subjectsthe appllcaotto a tivtl penalty of not morethan
00000o Eve hundred dollars($500). NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONS'IkIX:T10N
0 ❑1,a.owner of the property,or my employees with wages as their solem
compeatm
i ,will do the work and the structure h not intended or offered for
Osale(Sec.70K Business and Pmfeselmu Code:The Contractor.Lt..law
$ does not apply to an owner of property who builds or improvn thereon,and - l7CC.GROIRa RIS UNITSwhodoc such work himself orthroagh his own employees,provided that such
improvements are not Intended muttered for sale.If,however,thebullding or TOTAL:
improvement bwtdwithinamraro(complebNtheowner-buuderwill have
tFlg)Zurden of proving that he did not build or improve for purpose of We.). QTY. PLUMBING PERMIT FEEHppDzoNE APN
u L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.70K Business and Profession Code: PERMIT ISSUANCE
The Contractor's Llcame Law don m[apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improvn thereon, and who contracts for such Er,"with a FEE SUMMARY
cga(tactm(1)licensed pursuant to the Cwtractor.License Law. BACK FLOW PROTECT.DEVICE
LI I am exempt under Sea B&P C for this reason
DRAINS FLOOR RODF,AREA,COND. SANITARY Y N
Owner Date RECEIPT tl
WORKMAN COMPENSATION DECLARATION pfXTDRE&PER TRAP � SCIilX1L TAX Y 'N
❑I hereby affirm that I have•certificate of convent to eel!-inure,ora RECEIVE N
artiRate ofWorkem'C.f.tim lrumarnma certtfled copythereof(Sec. CAS EA. INCA OUTLETS PARK Y N
35011.Lb C.) 7/ REC=#
Polkytl (O GAS EA.SYSTEM-OVER 4(EA)
Cam anv fr/"EI i .-al A�� BUILDING DIVISION FEES
Certified yIA REeby tum sh CREASE/INDUSDIL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy V filed with the city inspection division.
CERTIFICATE Of EXEMPTION FROM WORKERS' GREASETRAI' PAID
COMPENSATION INSUBf
(ThlasecSb}VER-SANITARY-STORM EA.200FT. Dale Recei (# -
tlonneed not be complcted lithe permit mit V(Drone hundred dollars
(5100)ortees3 WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I¢rtifythat o the p peo i any work(auto m permit is Wus e
I Workers'
not employ any person In any manner so n to become�b t to the
Worken'Com eneatlo ova o(Callfomp.Date —'[-/ WATER SYSTEM/TREATING PAID
0 Z Applicant ,a le �Tl3s NEW RESIDENTIAL PLMB. SQ.Ff.
Z NOTICE H,after nuking this Ceni late of Exemptton,you Dale Remi t#
O should become subject to the Workers'Comperuatlon pmvlstoru of the Labor TOTAL:
N
Code,you=at forthwith comply with such provislmu or this permit.hail be N
G FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL IherebyafBrm that there is a comtroction lending agency for the perform TOp ELECTRIC FEE
D Z anceoftheworkfor whiehthbpermit is Issued(Sec.3097,Civ.C.)
OO Lender'.Name PLUMBING FEE
LL F Landrre Address QTY. . 'MECHANICAL PERMIT FEE MECHANICAL FEE
0 Turdfythailhavereadthb app0atbnaM sUtethattheabovetnfomutim
W bcomed.lagreetommplywithautltyandcountyordlnmceeandstatelaws PERMIT ISSUANCE FEES PAID:
'} relatingtobuilding corutrudlon,and herebyauthorlu repreaentativesofthb
U) city to enter upon the above-merty entlooed propfor WpecHen purposes. ALTER OR ADD TO MECH.
Date. Recei f#
V (We)agree to save,Indemnify an d keep barred.the City of Cupertino
Against liab1111 ,pidgments,meta and expenses which my In any way accrue AIR HANDUNG UNH(O 10,(00 CIM) SUBTOTAL:
ago Wt ity In co .q ce of the granting of this permit -
AIR ItANDUNcuNH(OVER lD,noocFk+) CONSTRUCTION TAX
5� 422 Igna rc ppIJest/Contractor EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllant or future building occupant store or handle hazardous HEATING UNIT(TO ID0,000 BTU) Date Reml I#
matertal as..fluid by ted Cupertino MuNdpal Code,Chapter 9.12,and the
Hnithand SafetyCede Section 25.532(a)? HEATING UNIT(OVER IDQ000 BTU - TOTAL:
❑ Yes No
Willtheappurantm Wmbuiidinga=pantuu Nuipmentordevima VENTILATION (SINGLE REEID) ISSUANCE DATE
which emit hazaadous air contemursnb n de0ned by the Bay Area Air
0 Quality Management District? BOILF.RCOMP(3HP OR 100,0110 BTU) p�
4Yn ❑No 6'— D
havc"ad the haz2uertutedalarequirements under Chapter6.95of BOILER-C'OMP(OVER 100,000 BTU)'
the G1vernla liealth&Safety Code,Sections 25505,25533 and 25536. 1 OCT
understand that if the building does not currently have a tenant that It b my NEW RESIDENTIAL MEOi. SQFT y Q O 199
resporachuctyto notify the occupant of the requirements which must be met, y t
priorlo Lauanc - aCertifiatc foccupanry. CITY
gent Date - ISSUED BY:
TOTAL:
OFFICE COPY