23001 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification I PERMIT NO.
Building Address
23.00
CITY OF CUPERTINO-BUILDING DIVISION 1 w 1
APPLICATION I 1 `PERMIT L
BUILDING-ELECTRICALPLiJMBINO-MECHANICAL CATEGORY CONTROL If
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSLIANCE ❑ ElLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(erimuna APPLIANCES-RESIDENTIAL OB DESCRIPTION
Ing Assislctfonfore,af Dlvfert. fthe Bupneseand Prr��fessioneCade,and my =ay /L ?�
Ilanse Is In fail force and dfeR�e, .O PANELS f•- ( o �- T�\
License Class LION
Date ContractorUP TO 2DO AMPS
.'�� 17f '� I
ARCHITECTS DECLARATION 201-1000 AMTS t l A
otO Zp lundenland my plans ahaB he used as public records. OVER 1000 AMT'S - � (` '�.FC.F��L�RARER 5/SQ.FI'.
Fi Licensed Professional SIGNSELFGTRICAL \CIA IIID `t..J VG
G OWNERER DECLARATION SPECIAL CIRCUIT/MISC U
71.., ]hereby affirmtha[]am exempt exempttromthe Colredois License the
oo qq following reason.(Section 70315,Business and Professions Code:Any city or
Fza'q county which requires a permit to construct,alter,Improve,demolish,or repair TEMP.METER OR POLE]NST. -
�� ❑ anyetmcturc prior to its lfeuance,alsorequlreslheapplant(er each perenitto POWER DEVICES
O 30fisaw a pBred statement that he Is licensed pursuant to the provisions of the core
yy ContraLicense Law(Chapter 9(e mmencingwithSection70M)ofOwl-
J eW.3.ftheB.sinessand Professns m
ioCedOmthathe bexepttherefromand SWP4MINC POOL ELECTRIC VALUATE,
a..•777 the bade for the alleged exemption. Any ,violation o(Scalon 70314 by any OI17LE.ISSWI•CHMFIX ORES
appliantfora permit subjects the applicant to a civil penalty of net more than
fl6,ur dyed dollars($500). '
Lf I,ae owner of the property, NEW RESIDENTIAL ELECTR SQ.FI. STORIES TYPE CONSTRUCTION
p perry,or my employees with wages as their sets
a compensation,will do the work and the stmdure is not Intended or offered for
❑ .1.i3ec.70K BuaL�eu and Pmf esdam Code:The Contractor's Lt..law
3$
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who dwseuch work himself orthreugh his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement issold within one yearofcompidion,the ownerbu+lderwill have
t"rden of proving that he did not build or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ 4 as owner of the property,am exclusively contracting with licensed p {IT ISSUANCE f
contractors to construct the project(Sec.7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EM
Wilds or Improves thereem, and who contracts for such pCajects with a FEE SUMMARY
%R¢acmr(s)Bernard pursuant to the Cimmuctori License Law. 0AIX FLOW PROTECT.DEVICE
[:]I am exempt under Sec B A P C for this reason
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECQPTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP �..�• 5CHOOLTAK Y N
❑f hereby affirm that 1 have a ttrtl0me of consent to self-Insure,w a RpC�.N
mrtlficateofWorrkke�n'CompewHoCniruuranmware IfIMm [hereof(Sec. GAS-EA.S1,SI.FA11 WC4 OUTLETS PARK FFE Y N
Policy N3800, bC)5/=/ �� r �/YI Y� ��6 ��S.1F RECEIPT
(n ny GAS.FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
ertfied ropy is hereby te city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified ropy b flied withh the city e Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recei tIl
(Thissection need rat Mcompleted lithe permit Vfaromhundred dollars
(SIOO)oify that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill not thato the person In
the work
sean t b co permit is Issued,
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREAUNG
Worken'Compensation Loss of California. Date PAID
-
ZZ Applicant NEW RESIDENTIAL PLMB. SQX.T. Date Recei t#
Z O NOTICE TO APPLICANT.If,after nuking l his Certificate of Exemption,you
should became sub)ect to the Workers'Compensation provisions of the Labor TOTAL:
fq Code,you must fon hwllh comply with such provisions or this permit shall Im ^.
W 7 deemed revoked. BUILDING FEE C)
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihembyafflrm that there is a comtructlon lending agency forthe perform- ELECTRIC FEE
D Z anm of the workfor which this permit is Issued(Sec.3097,Civ.C.) T
U O Lender's Name PLUMBING FEE
LL 1= Lenders Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWI=anifylhatlhovereadths.ppBatbnanda tethauheabove+nfomut+on
1 is cornet,l agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authorize representatives of this
H Z city to enter upon the above-mentioned property for inspection purposes. ALIFRORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless the City of Coped[no Date Recei tM
I..I agaW bIItles,jadgerenn,mise and expenses which may In any way seems AIR HANDLING UNIT(TO 10,OJO CFM) SUBTOTAL:
age] d City N consequence of the grantiag of this Parnlltt/
AIR HANDLING UNIT(OVER 10,000 C1M) CONSTRUCTION TAX
sIF ns of ppRam/C.nt.cto Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
rill applicanfor future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tis
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code�+.-S�ection 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL
E]Yes - L_I No
Will the applicant orfutum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminantsas defined bythe Bay Area Air ^ O
•� ality Management Distrid7 BOILER-COMP ClHP OR 100,000 BTU) 07j
s O Yes No
havc read the hazardous materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU)
the California Health A Safety Code,Sect ions 25505,2SS33 and 25534,M1 ®v 18 1991
u Menta rid that if the build Ing don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQXT '
responsibility to notify the occupant of the requirements which must he rant
prior to issuance of a Certificate of Occupancy.
CITY Ur CUrnnlirvv
Owner or authorized agent Date
TOTAL: ISSUEDBY..
OFFICE COPY