20398 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
building Protect Identification PERMITNO.
Blloo3-7S BvANE 20398
nera ante: Phol
D HI L L'0'V CITY OF CUPERTINO-BUILDING DIVISION
contractor'°"ora: �� � Lic.No: APPLICATION /PERMIT
BUILDING-ELECTRICAL PLUMBINGMELHANICAL - CATEGORY CONTROL#
Archltm/Englmer. Lk.Nee
�` QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: !i LLJ-1 J�� a PERMITISSUANCE ,(� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l son Demsed under prwWonsof Chapter 9(commm APPLIANCES-RESIDENTIAL JOB DFSCRIrIION
IngwithSmion7000)ofDMsion3ofthe Bupnessand Pmfe onsCode,and my
license la In full lora and effect. PANELS s P�vZ` 1
license
Lff c }`J
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�nn reO Zp I understand my Fiscal be used u public records. OVER I ODD AMPS SQ.HT.FLOOR ARFA $/SQ.FT.
k o Licensed Professional SIGNSELECTRICAL
�< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
2s, 4 I herebyaffirenthal l am exempt fromthe Contractors LicenseLawforthe
qqw following reason.(Section 7031.5,Business and Prefeal Code:Any city or 0�
r ❑ county which requires a permit to mratruct,alter,improve,demolish,or repairHOUTLETSSVVITCHES�FIXTURES
TEMP.METER ORPOLE INST.
anya signed pater tent that Is is lice sed Fru sul t the provision
of t e
rr/E
file a signed statement that M ls licensed punumt to the provislon of theLOWER DEVICES
Oµ ContnRoe.License Law(Chapter 9(commencing with Sal 7000)of Divi. VALUATION
30 sioo3ofthe Busnneasmd Professions Cade orthat heisexempttM1ercfromand SWIMMING IDOL ELECTRIC
S the basis for the alleged exemption. My violation of Section 70315 by any
<5 appliantfera permit subjects the applicant to a civil penalty of mon,than
eve hundred
nerofthepro NEW RESIDENTIAL ELECTR_SQ.FT, STOWGS TYPE CONSTRUCTION
�I,es owner of the property,or my employees with wagea as their sole
C 6 compensation,wllldolhe w¢k,and lhestructure Is not intended or offered for
.1.(Sec.70Kthainensand Professnoru Code:The Contractors License IAw
R�$ does not apply to an owner of property who builds or lmprwes thereon,and
EE who doesel work hiona rthrough his own OCC.GROUP RFS UNITS employees,provided that such ^�
impmvementsarenotnntendedoroffemdforsale.Ifhowever,theWildingor TOTAL: C
Improvement haold wlthnoneyearofcompletlogtheowner-bullderwill have
t rdan of proving that he did not build or Improve for purpose ofsale). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN.
Lj I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7064,Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who
buALTER-DRAIN Is VENT-WATER(EA)
Wilds or improves thmwry and who contra fa such plojecm with a FEE SUMMARY
cgal(+ctort°)Ikxnsed pursnt uato the Contractoes License Law. gpCR FLOW PROTECT.DEVICE
Lf I am exempt under Sm B&P C for this reasonOUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEIPT Y
WORKMAN COMPENSATION DECLARATION
C3' m r hereby affirthat I have a car i firate of consent to self-insure,ora FIX'ILRF.S PER TRAP SCI100L TA% Y NRECEIPT 1
certRnateofWorkers Compenattonlnurmmmacednfiedmpythemof(Sec.C GAS EA. INC.40UILETS PARK FEE Y N 3800,Lab C3 _
Polley# RECEIPT
Cm GAS EA.
BUILDING DIVISION FEES
Certified copy is berebyth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V flied with the city inspection division.
CERTIFICATE OF E%EMPI'ION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SAMTARYSTORM FA 200Ff P Date Recei ted
(
(I¢Ma lres.)n need not be completed[the permit V leron hundred dollars
5100lthat
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Irtlfy that In the pepormanaof the wakfor wMch this permit is wued,
I shall not employ any person in any manner n al to become subject to the WATER SYSTEM TREATING
Workers'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recef tN
'Z z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Comperoation provision of the Labor TOTAL:
N Code,you most forthwith comply with such provision or this permit shall be
lL j decrrM revoked. BUILDI G FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O Ihereby affirm that there is a construction lending agency for the perform, ELECTRIC FEE
0 Z anceowork forwhichthls permit is issued(Sec.3097,Civ.C.) TOTAL:
O O fthe Lcnder'aName PLUMBING FEE
LL F Lenders Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1renlfythat l have read thisapplicationand statethat theaboveinformatlon
lscorrect.I agmato complywith all city ami county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
} 1 relating to Wilding connection,and hereby authorize repon"mativesof this
?N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADOTO MECH.
(We)agree to al indemnify an d keep harmless the City of Cupertino Date Reel
V
against liabilities,fudime ts,cope and expenses which may In anywayaccrus AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL'
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sngmtureaf Applicant/Contract¢ Date EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WOltheappllant orfuture building occupant store or handle hazardous HEATING UMT(PO 100,ODO BTU) Date Recef tN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hcalth and Safety Code Section 2553200)2 HEATING UNIT(OVER 100,000 BTQ - TOTAL: Trial
❑Yes r]No -
Willtheappliantorfuturc building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUd 'FE
which emit havrdous air contaminants as defintd by the Bay Area Air
Quality Management District? BOILER-COMP OH POR 100,0(0 BTU) JUN
Yes 1�I No Ju 4
have read the hazardousmaterials requirements under Chapter 6.95 of BDI.ERCOMP(OVER 100,DOD ITU) 799
the California Health&Safety Cade,Sections 25505,25533 and 25534. I
un rstand that lithe building don not currently haveateren4 that It is my NEWRESIDEN7IALMECH. SQFr. I�tys.�a�.
onstbllllylonctifylh occupant of the requirements which must be met 1(6� �yRpl asac
alortotssuanco ifiateof Occv an ,
Oweel."LArrild a ent Date ISSUED BY:
TOTAL:
OFFICE COPY