23636 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Bnt/mOzdd a7/4 AN14 A2P60Q 23636
wrens ante: - one JAL UAlh
C,ICF A j2A CITY OF CUPERTINOQBUILDINGDIVISION
. Contractors Name: Lic.Na APPLICATION /PERMIT . S-7-9.2.
2BUILDING-ELECTRICALPLUMeING-MECHANICAL CATEGORY CONTROL p
Arciawa/Engineer: Lic.No:
QTY.F�I ELBGTRIG PERMIT t =1 FEE
:BUILDING,PERMIT INFO
Add... . ��Q - PERMIT ISSUANCE .". .EJ El . , 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that7am licensed underprovlslona of Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith SeMon7000)of Divislan3ofthe Rusinssand PmfesslonsCode,and my -
Llren.iClrt full force eft a D 35 l PANELS
Date ContractorUP TO 200 ANUS
ARCHITECTS DECLARATION 201-1000 AMPS
0
2 I understand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
qO
o(0 Licensed Professional SIGNS ELECTRICAL � - I
'¢- m OWNER-BUILDER DECLARATION
z IherebyafOrmthat lamexempt frdmthe Contractors License Lawforthe SPECIALCIRCUIT/MISC _
pp f.q following reader.(Section 7Bi1.5,Business and Professions Code:An a or + !', �i
FZ�iq county which rcquiresa permittomnttact,alteq Improve,demoilsh,orrepalr IEMP.METD20RPOLE IN C„r� L' tl
anystrocture prlorto its exuance,aisorequiestheappllrant forsuch permit to
Ofile a signed statement that W&licensed pursuant to the provisions of the POWER DEVICES
Contraetorb License Law(Chapter 9(commencing with Section 7000)of Divi-
�OSsion3oftheBuslnessand ProfessionCWd )orthatheisemmpliherefromand SWIMMING POOL EL RIC VA UATIO (og:36. - -
�'•t the basis for the alleged exemption. Any violation of Section 7001.5 by any -`
o re
applicant for a permit subjectathe applicant to a civil penalty of not mothan OUTLETSSWITCHFS-FIXTURES
5 five hundred dollars($500). NEW RESIDENTIAL ELECTR
❑I,as owner of the property, SQ.FL STORIES TYPE CONSTRUCTION
p ork,a or my employees with wages r thele sole
compensation,will Bothe work andthes Code:TIs he
Cointended or offered for
q sale(See apply toBusiness
ow and Profession Code:The Contractors License Law
don not apply torn imselforproperty who Wilds nemporimproves thereon,ovidedthats such
OCC.GROUP RFS.UMTS
who does auchwarkhlm.Iorthrough his ownemployees,provided that®rch
Improvements are not intended or offend for sale.If,however,the building or TOTAL: -improvement I,sold within one yearofcompleilon,the owner-builderwill have i
thll.burden of proving that hedid not build or improve for purpose of sale). QTY. '{:. `.$LUMBINGPERMIT FLOODZONE APNr
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7654 Business and Profession Code: ..
The Contractor's License Law doer not apply to an owner of property who
buALTER-DRAIN&VENT-WATER(EA)
Wilds or Improver thereon, and who contracts for such IrWiects with a
,0tt.jj''aant a (a)Rcemodp...anotheContractor'sLlan.Law. BACK FLOW PROTECT DEVICE " r C`''FEE;$UMMARYF
LJ I am.exempt under Sec. ' B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y -N
Owner - Date
WORK MAN COMPENSATION DECLARATION RECEIPT B
FIXTURES PER TRAP SCHOOL TAX Y_ N-
1f hereby affirm that I have'.certificate of con.nt d rpythsure,ore RECEIPT M
3 00,Ub C.entroWorkers'Compenatlonlnuranm ora certified ropythereof(Sec. GAS FA 52•g.I•FM IINC.d OUTLETS PARKIM Y N
Polis Lab C3 ^ /Fy.y/ ('
Polity p .1 i'S`f G f R p
COAS M-
EA.SYSTEOVER 4(EA)om /�6 �CestnlOed copyV hereby(urNshed. - BUILDING DIVISION FEES
E]Candied copy is filed with the'city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANFLARY-STORM FA.700FT Date Remit#
(TEissection na no[be completed lithe permit R(Drone hundred dollar
($100)orlesa.) WATER IIF.ATER W/VENT/ELECTR ENERGYFEE Y N
I llnor that o any phe erson
I any m nner so as to become
permitI.issued, - —
I shall not employ any person In any manner at as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID -
O Z Applicant
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDFMTAL PLMB. SQ.FP. Date Recei t#
should become subject to the Workena Compenation provisions of the Labor TOTAL:
CC fA Code,you must forthwith comply with such provislon or this permit shall be BUILDING FE
LU j deemed revoked.
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebya((Irin that there is a construction lending agency forthe perform- TOTAL: ELECTRIC FEE
0
an ofthe work(orwhich this permit is issued(Sec.3097,CIv.C.)
(,) Lender's Name PLUMBING FEE "
IL F Lenders Address QT,Y: "( MBCI'IANlCAL;PBRI411T .'�'.`:FF*E''t-' MECHANICAL FEE
O WI certdythat I haveteadthisapplicatlonand andethatthe above Information
(L iscorrect.I agree to comply with all city and county ordinances and gate laws PEftMTTI55UANCE FEES PAID:
N relating to building construction,and hereby authorize representatives ofthis - . .
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Reeei [#
V _ - (W)agree to save,Ihdemnify an d keep harnde.the City of Cupertino P
.gad tl abilities,jodgmente,c sand expenses which may In any wayacerue AIR HANDLING UNTT(1'010,000 CFM) SUBTOTAL:
net Cityin cons uen of the granting of this permit.
�j AIRHANDLING UNIT(OVER 10,000CIT0 CONSTRUCTION TAX
Sig h cofApp� t/Contr or ate C/ EXHADSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARD MATERIALS DISCLOSURE
Will the appl ant or fu core building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as dented by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Flealthand SafetyCod a Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TAL•
F-1YenNo
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) 1$ CI CE DATE .
which emit hazardous air contaminants as defined by the Bay Area Air,
Quality Management District? BO
ILER-COMP(3FE'OR 100,0(0 BTU)
_ y
Yas No `
gki �7
.. have read the hazy us materials requirements under Cha pier 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Celifomla I Iealth&Safety Code,Sections 25505,25533 and 25534.I /� 1 IIyU
understand that Ballythe the ing occupant of t ementimments tenant,that b iset NEW RESIDENTIAL MECH.' SQ.17. CIS Vf BlitCn
morto bliita e,rotifytheoccupantoftherequlrcments which most be met 1,
prior to L.uance of Certificate of Occupancy. -
Owner or authorizedagent Date ISSUED BY +
TOTAL;
OFFICE COPY , '