20461 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Rulldin Pro'eaY tdentlfkaHon PFJMT NO.
Bz7`d9 �AR"f)F (3� A Kik sea 20461
wnen ante: one: A
vE"(t(,• -� ToGkSIFDoNrE- CITYOFCUPERTINO-BUILDING DIVISION
nntraaoraName: , ^1✓ � O
cLic.No: APPLICATION / PERMIT 1
V a— BUILDING-ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL N
Archlte /Engineer LIC.No:
app T p �`�� a QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
__ A�rcss sl�ak-R (06R'�J4�11�N �T�
PERh4TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S ECLARATION
I hereby affirm that l am licensed under provLslons of Chapter 9(cxm xmc- APPLIANCES-RESIDENTIAL JOB DESC ON
Ingwith Section 70M)of Divlalon3ofthe Buusiimmand PmfeskwsCode,and my
license
License Clam Ir— Lictcil ;T-' 9• PANELS xLpL(/lK QIl�/�T'
Date r,13,1ky Contractor 6'a 201TO2A0 AN"MPS �RRT — 9-
-� AIfCHITECTS LARATION
p'Z [understand myplansahallbe used apubherecords OVERIOOOAMPS SQ.FT.FLOOR AREA I S/SQ.FT.
O
Licensed ProfessionalSIGNSELECTRICAL,
t SP
¢ OWNER-BUILDER DECLARATION
a ECIALCIRCUIT/MLC
zp, Iherebyaffim that l am exempt fromthe Contractor's License law for the
qq following reason. 7031.5,Business and Professions Code:Any city or
0 t'ty countywhichrequimsapee tWmmtmdalter,lmprove,demolhh,orrepair 'IEMP:MECERO POLE IN
any structure prbrtof.issuance,at=requlmthe applluntfonuch pernJtto POWER DEV[
6 file a signed statement that he h licensed pursuant to,the providers of the
3 ir'o'n Contredors License Law(Chapter 9(commencing with Section 7000)of Divi-
SWIMMING POOL C
�Og sfon3oftheButlnasand Professlo.Code)orthathehexempttherefromand VALUATION
¢S the bash for the alleged exemption. Any violation of Section IMIS by any ctOUTLETSSWITC
applicant fora permit subjects the applicant to a dvil penalty of not more than
22 five hundred dollars(g5W).
�n ❑I,a owner of the property, NEW RESIDENTIAL EI TR SQ STORIES TYPECONBIRUCTION
p party,or my employees with wages r thele dole
.1.(Secampec.
70K Hu.beethe work and ionsthesCode;
h not ontractortended or offered for
q ale(Sec.7044,Buelriesa and Professions Code:The Contradore Llceae Law
does net apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
whodoessuchworkhlmself wthrrugh hlsownemployea,provided thatsuch
improvements are not Intended orof(ered forsale.If,however,thebulidingor TOTAL:
improvement Issold within ooeyearofcompldlon,the owner-buRderwlll have
t}Lturden of proving that he,did not build or improve for purpose of sale.). QTY, PLUMBING P RMIT FEE FLOOD ZONE APN
Lf L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW&VENT-WATER lEA1
Wilda or Imprmeea thereon,and who contracts for such pVoota with a FEE SUMMARY
m�ad.Hs)licensed pursuant to the Contracers Llcenss Law. BACK FLOW PROTECT.DEVICE I am exempt under Sec. B&P C for this reason
Owner Date
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
- RECEIPT N
WORKMAN COMPENSATION DECLARATION FO(TURES PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have a certificate of consent to self-insure,or a RECENT N
.� nrtifirate o(Workere Compensation Insurance me certified cepythereof(Sec.
3800,Lab CJ - GAS EA.SYSTEM-1 INCA OUTLETS PARK EEE Y_ N_
RECEIPTX
^- PolicyX GAS M.SYSTEM-OVER401A)(EA)
Com any _ BUILDING DIVISION FEES
Cer11(ied
FTcopy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
191 Certified copy h filed With the city impaction divlsion.
'W CERTIECATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORMEA.200FT. Date Recei t#
(TNssection need not becompleted if the permit lsforonehundreddollara .
($100)orless.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y N
I certify that In the performance of thework forwhlch this permit is issued,
I shall not employ any person In any manner do as,to become subject to the WATER SYSTEM/TREATING
Worker%Compensatbn Lawsof California.Date PAID '
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:if,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisionsof the Labor TOTAL:
W Code,you moat forthwith comply with such provhlonsor this permitshall be BUI IN
W > deemed revoked.
G FEE
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebya(firmthat there is a construction lending agency for the perform- TOTAL: as ELECTRICFEE
Z ance of the work for which this permit is earned(Sec.3097,Civ.C.)- W
V Lenders m
Nae
O PLUMBING FEE ;Z
F Lenders Address QTY. MECHANICAL PERMIT FEE
OW IcertlfythatlhavereadthisapplIationandstatethattheaboveinformation MECHANICAL FEE
6 is correct.I agree to comply with all city and countyardinances and state laws PERMITISSUANCE FEES PAID:
>- CL to building construction,and hereby authorize repromativesofthis
f N city teenter upon the abevcmentioned property for lapedlon purpose.. ALTEROR ADD TO METH.
? "(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against liabilities+pdgnnmas,massed expenses which may In anywayarcme AIR HANDLING UNIT(TO 10,WO CFM) SUBTOTAL'
against said City in consequen of the granting of this permit
—� AIR HANDLING UNIT(OVER 10,0)0 CPM) CONSTRUCTION TAX
Signature of Applicant/Co raxmr Data FXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000BTU) Date Recei t#
material a defined by the Cupertino Municipal Code,Chapter 9.12,and the
Heahhand Safety Codt(�n25532(a)2 HEATING UNIT(OVER 100,000 BTU) - TOTAL: 12yeno
r-1Yes LJ"'u,
Will the applicant w future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS$ TE
which emit hareedous air contaminants as defined by the Bay Area Air
w silty Management Dist l BORER-CAMP OFN OR 300,000 BTU)Yes
Yea o y
avc read the haza s materials requirements under Chapter 6.95 of BOILER-COMP(OVER I W,ODO BTU) JUL
1 °i
the Cailforola Health&Safety Coda Sections 25505,25533 and 25534.I
understa red that if the build Ing does not mreently,have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
respoaibllity to notify the occupant of the requirements which must be met City of Cunertino
prior �nc .a mod Oc p� --
Owner or authorized agent Date TOTAL: ISSUED BY: �
OFFICE COPY