19739 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES BALL POINT PEN ONLY
Building Pra'ect Identification PERMITNO.
°Bat gAas, 19739
wners
Piton, /'/
`ep 7T e. CITY OF CUPERTINO6BUILDING DIVISION
congatter.N.nte: 'sec.No: APPLICATION I PERMIT
�I BUrLDINGELECTRICAI.PLUMBINGM HANICAL CATEGORY CONTROL#
rchime/Engineer. a Lac.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.
P2NSSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ioflrtnllstlemBce3.ftheunder sinemaomofChapter sionia9de,and APPLIAN RESTDENfIAL JOBDESCIEPTION
I.cen.1 1.fon force and
efelon3otthe Buslnessand ProfeaslonsCAde,and my
Ecense fs m 6,u mrce.na erner PANELS
License Chssic#
Dateontrettor ,. RO:bur extsfi -
ARCHITECTSD CLA A co 701-1 OOOAMIS
� plans� (understand my plaahalbe used upubec records. OVER 1l)XIAMPS SQ.FT.FLOOR AREA 5/9Q.FT.
Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
Z p„ 6I hereby affirmthat I am exempt from the Contractors License Law for the
0,
qqqqqq following mason.(Section 7m1.5,Business and Professions Code:Any city or I"'Py countywhich requlres a Parrott toccoa us,,alter,improve,demolbh,orrepair TEMP.METER OR POLE INST.
3 ia,-si red pater toits that
he Is aW rcquircathant to the
of to
Q POWER DEVICES
O U Ole a signed statement that he is Bcensed pursuant it the provisions of the
Communes License
.ndProap W=Commcneagwith Section
prtthe0)of Divi- VALUATION
BOJ the W9 for
aIle and Profption. Any
f exemlrt 7031.5by and SWIMMING Ii70L ELECTRIC
Yd•77 the beans for the alleged exemption. Any violation ofSection
not m re any
65 five u tfor a perMlsubjectstheappllcanttoa civil penalty of not rtnrethan OUTLETSSWITCIIESFIXTURES 1 Or•��
five hundred dollars ISM' NEW RESIDENTIALELECTR FI. 1 V
�I,as owner of the property,or my employees with wages as their sok SQ STORIES TYPECONSTRUCTION
7a compensation,will do the work and theetructure at not Intended or offered for
D sale(See.70K Business and Professloru Code:TM Contractors License Law
$ does net apply to an owner of property who Wilds or improves thereon,and OCGGROIIP HIS.UNITS
whodcessuch work himself orthreugh Msown employees,provided that such
Improvements are not intended oroffered forsale.If,however,thebullding or TOTAL:
improvement atsoldwithlnoneyearofcomplelogtheowner-budderwlll have
tFakurden of proving that he did not build or improve for purpose of sale.). ('Ty, PLUMBING PERMIT FEE HOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Ser.7096,Buslnessand Professions Code:
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VFM-WATER(E V
builds,or Improved thereon,and who contractse
s for such ptojes with a
cgjWctm(a)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
ven
Lj I am exempt under Sne. B&P C for that maOUTS I DE FEES
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
Date RECEIPT If
WORKMAN COMPENSATION DECLARATION SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,or a R���
cerUOcateofWorken'Compersalionrssurance oracertl(bd copy thereof(Sec. G BySTFM-1 INC.60 RK It FEE Y N
Pol3800,Lab C.)
Com an GA& .SYSTETI-0VER6(EA) RECENT#
Y ,-� 1 i BUILDING DIVISION FF.ES
Certified copy at hereby furnished. EASE/INDUSIRL WASIE I LANCHECK FEE
edified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CkEASR IMP 1 C AID
COMPENSATION INSURANCE SEWERSANITARY STT3AM EA 200PT. -- Date Recei t#
Q)msection need not be completed If the permit b(Drone hundred dollars
GSI m)eifyth WATER HEATER W/VENT/EUECTR ENERGY FEE Y N
I certify that o the performance any
manner
as to b ohms permit 1.Issued, —
1 orkha not employ any person In any manner n u to become subject to the WATER SYSIFM/TREATING PAID
Werkera'Compensallon laws of Ca Womb.Date
O Z Applicant Date Recei t#
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMH_9Q.Pr.
CC
should become subject to the Workan'Compere dlon pmvbiom of the Labor TOTAL:N Code,yourrmstforthwithromplywithsuchprovataomorthleper tshallbe
W > deemed revokUed. -
a CONSTRUCTION LENDING AGENCYSEISMIC FEE
for
Iherebyaork far tthem atacomwctssud(Se lending agenry .) perform- TOTAL ELECTRIC FEE
7 Z ance of the er'.Nwork for which this perMtatatsuetl(See 3097,Co..C.) (�'
02 I<Mers Name ` PLUMBING FEE
LL l- lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iunify that l have mad this application and date that the above Information
1 Is corms.l agree to comply with a ll city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
W relating to building conduction,and hereby authorize representative.of this
Z city to enter upon the above.mcntioned property for inspection purposes. AL ORADDTOMECIi. Date Recei t#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabWtles,Pdgmene,codsand..pm.which may an any wayacerue AIR FIANG UNIT 9010,OX CFM) SUBTOTAL:
aga irot said City In coomquence of the granting d this permit.
AIR HANDLi UNIT(OVER IOpa CFM) CONSTRUCTION TAX
Signature of Appllcam/Contractor Date EXHAUSTHOOD DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applica otorfuture building occupant store or hand le hazardous HEATING UNIT(TO IDO, 0BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
I ealth and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100, BTU) AL:
MYes M No
Will the applicant or future building occupant use equipment erdevices VENTILATION FAN(SINGLE ) 1$$U DATE
which coot havardousalrrict? rsnts as defined by the Bay Area Alr
Quality Management DL+Mct7 BOILER-COMP pFNDR1(10,(XD BTU)
Yn n❑No r
have read the hazaNe..materials requirements underChapter 6.95 of BORER COMP(OVER 100,000 BTU) /�TI.,I�.t
the California,Health&Safety CodeSectio 75505,75533 and 755M.1 NI,J n!1 rritn?{tIR�
understand that lithe Am'�f
es ot rently haveatenanpthmitbmy NEWRESIDENTIALMECIi. �.. t y .
nspersibiilty to nett o ( rcqulrementawhlchmustbemet - -•
p p.os f panty. �+ y�� �•� ��}_
OwnsOwnertd auth(Tdl agent Date TOTAL: ISSUED BY'. X1s\-\�00—
OFFICE COPY