23042 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Proed Identification
Buaasaaa�adb g Add. PERa MIT N23042
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�T - CITY OF CUPERTINO-BUILDING DIVISION
c°R ado shame: • V Lie.Na: APPLICATION / PERMIT !!O
per' BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROLp
Archlleci/Engl r. Lie No:
A/r ��5 w e e z BUILDING PERMIT
�03 ! Fa rI'LUMh
e s QTY ELECTRIC PERMIT FEE NG MIT INFO
Address: / NIMFT
PERMITISSUANCE O ❑ ❑
LICENSED CONTRACT R'S DECLARATION
I hth Sb M rn 7OOD)o Divie 3-fth-sed derprovltlansof Chapter9(mmmen APPLIANCESRES7DEMTAL
inenseI In fon Imer.(DlViect. theBupnemand Profeslonv Cade,and
liana Is in a force end .If PANELS
Diocese Cla® Cnn
Date Contmcior
ARCHITECT'S DECLARATION 1014000AMI'B
r10O ]understand my pkmsluB be used as pubecremNv. OVFR1000AMP5 'SQ.FT.FLOORAREA 5/SO.FT.
Lkenxcd Pro(emio.l SIGNS ELECTRICAL
kG'7� OWNER-BUILDER DECLARATION SPECIAL CEtCUIT/MISC
I hereby affirmthat l am exempt from the Contrador'sLicense law forthe j /1.
09 OZ q (ollowingresson.(Seelon7m]S,BuMnessand Pmfuddkms Code:Anydtyor 'I tf / 1
q =ntywhlchrequlrmapermlttommtruct,alter,Mpave.de.11ah,orrepdr T ARMETERORPOLEINSI. 1� �1
yy 33 anystmRure Prbrm its Wuame,a4oaqubestheapp0ont forsuch permit to POWER DEVICESI,`{I 1�
K file a signed statement that he Is licensed pursuant to the provisions of the B _ll U
ww3u, Contractor's License law(Chapter 9(commencingwith Section 7000)ofDivi.
�O pon3o(the Business end ProfemloruCMe)arthat heisexempttherefromaM SWIMMING OL ELECTRIC 1� AL TION
the basis for the alleged exemption. Any Violation of Section 7071.5 by any kit
O f;` sppBcantfor.permit subjects the applicant to a civil penalty o(nat more than OUTLETSSWIICHESFIXTURES L
GG77$ rive hundred dollars($Soo).
�n ❑L as owner of the property,or my employees with wages as their sok NEW RESIDENTIAL ELECTR e-4.FL STORIES TYPE CONSTRUCTION
compensation,will do the work end the structure knot intended or offered for
O sale(Sec,7044,Business and Profemioru Code:The Cantracior's License Law
�$ does Rot apply to an owner M property who builds or improve thereon,and
who does such work himself or through his own employees,provided that such OCC.GROW IUNITS
lmproverrenk are not Intended.,offered!(oudik.If,however,the building or TOTAL:
improvement ie sold within oneyearofcompletlon,the owner-bullderwill have
tl)gj2urose of proving that he did not build or improve for purpose a(uk.). Q'1y, PLUMBING PERMIT FEE LOOD7DNE
LJ L as owner of the property,am exclusively contracting with licensed FAPN
contmems to mnstrod the project(See 7014,BupnemaM Pmf.jmm Co,,.: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wild. or Improves thereon,and who contuats for such poo#ds with a ALTER-DRAIN&VENT-WATER(EA)
am eta(s)licensed punuant to the Contra,,-.License La151w.
FEE SUMMARY
exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE
Owner DNe DRAINS FLOOR ROOF,AREA,CQND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION REC=p
haol hereby affirm that I have.certificate of consent to self-Insure,or.a FI)CIURES PER TRAPSCIiOOL TAX Y N
ce00,1.b of Workere'Compenution Iruunnceora cenlfkd copythereof(Sec. RECEIPT p
polis Lab C.) GAS EA.SYSTEM-11NCAOUTLETS PARK FEE Y N
policy M RECEIPT p
Co. anyMCAS EA.SYSTEM-0VER4(EA) BUILDINODIVISIONFEES
�CeriOM copy is hereby furnished.
Certified copy Is filed with
the city inspection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectum.ced nor becemplciM lfthe permitIslar ane
(SIM)or less.) hundred dollars SEWER-SANITARY-STORM EA.2001717.. Date Reoci t#
I certify that in the performance ofthe work for which this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I shall not employ any person in any manner m u to become subject t°the -
O Workerv'C°mpenutlon lawsofCallfomk.Date WATER SYSTEM/TREATING PAID
Applicant
Z 0 NOTICE TO APPLICANT:H,aher making this CertUkm of Exemptio",you NEWRESIDENTIALPLMB. SQ.FT. Dale Recei t#
ahold become subject to the Worken'Comperuatlon provisions If the Labor TOTAL'
WN7 Code,you trwat forthwith comply with such provkiov or this permit shall be
> deemed revoked'. B N �+
ll G CONSTRUCTION LENDING AGENCY - ILETSEISMIC FEE 1 -
I hereby affirm that there k a coatrucilon lending agency forthe perform
D Z once of the work(orwhlch this permit Is Issued(Sm 3097,CW.C.) TOTAL ELECTRIC FEE
U O 4nder'aNam PLUMBING FEE
LL L) Lender'ti6thelh QTY, MECHANICAL PERMIT FEE MPAID1.
O W Icedltyihatl have read ihisappgotionand nate thaithe above ln(ormatlon
IL Iscormot.I agreeto complywiNall dtyand county ordinances and pate laws PERMIT ISSUANCE
} W relatingtobulldNgmnatmt m,nMhmbyauthompresentativeo!this
Z dtytoenterupontheabuvmmntbnedpmpeny(orlropMionpugp . ALTER OR ACUTE,MECH.
V — (We)agree to save,Indemnify an d keep harmiess the City of Cupertlno eCei t#
against liabilities,Pigments,Insisted expense which may inany wayacorue AIRHANDLINGUNIT(T010,0DOCFM) OTAL•
ago et sold City In ou"s nor hegraesti al lhl ennit. ATRHANDLING UNR(OVER IO,000CFM) X
MATE. A/
Igm o Applicant/ it cior Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HATH DOUS MATERIALS DISCLOSURE
Will the applieant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) '
material.,defined by the Cupertlna Municipal Code,Chapter 9.17,and the Date Recei t#
hkalth and Safety Code Section 25537(ap HEATING UNIT(OVER 100,000 BTU) TOTAL:
00
YeaNo
Will the applicant Ora building occupant use equipment ordeviess VENTILATION FAN(SINGLE RESIDI ISSUANCE DATE
which emit hazard...air contaminanta as dented by the Bay Area Air
Qu lily Marugsnxmt Dktrkt7 BOILER-COMP OEMs OR 100,0M BTU) PAID
4Yes No
1,Y' mad the hieraRs outerkla requirements under Chapter6.95of BOILER-COMP(OVER 100,000 BN)
the California Health&Safety Code,Sections 25505,75533 and 25534. 1 NOV ��
9A
understand that ifthe building doe nor,currently have a tenant,that It Is my NEW RESIDENTIAL MECH. $Q1.7
responsibility to notify the oaop int of the requirements which must be reset Y� 1a7�1Q
prior to Issuance of a Certificate of 0cmpancy. C11
Y
utCurcnlly
Owner or authorised.gem Date
TOTAL: ISSUED BY:
OFFICE COPY