19845 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Proem ldemlflaBon PERMITNO.
Buildo�ree:r 19845
vier. ams: Phone:
737-STT CITY OF CUPERTINO-BUILDING DIVISION
MhCantram.e.Name: LIe.N.: APPLICATION / PERMIT
C� k 0 21'"0: BURAINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL Y
Archi /Englnrer. LK.Na
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ 1:1 �j ❑
LICENSED CONTRACTOR'S DECLARATION LJSL
I herebyaffirtn that not licensed under provisions.!Chapler9(co. APPLIANCMRESIDENRAL JOB DESCRIPTIONingwhh SroBon7000)ofDIvidoo3 ofthe Butlnessand PrefesslonsCode,and my ,
Iicease b in lull f. d effect p PANELS
Llanse Cis LIcIf 7. �0 o _ 'fP�7 L (ham (/�
Date'�Contano���'r 1 �L�.U I h rte— I"Q
ARCHITECPS DECLARATION 201-1000 AMPS
1Q+�DCO I.Md.tand myple.ah.Ubeused upubacrec.rda - OVE4I000AMPS SQ.IT.FLOOR AREA
E (/ Licensed Professional SIGNSELECTRICAL
«rid FL]`Il OWNER-BUILDER DECLARATION SPECIAL CIRCUPI/MISC
t E, � I hereby affirm that l amexempt from the Contractor's License Law for the
following redeem.(Section 7m1.5,Buslness and Professions Code:Any city or
O ti� TEMP.MEfER ORI'OL
Fv� cotntywhkh regWrr'ispermitmm.t.uirestheapmve,tiemsuch,orrepae
anystrocNre priortstatement
Its issuanthat
he is Ilm nsad pursuant to the provisor ions
of permitto II�WF.R DEVICES
floe a actor's statement that he t Brenud pursuant to the provisions of the
Contractor's License Law(Chapter9(commencing with Section 7000)o(Divi.
H�O"J mbm3 ofthe Business and Pr.famdomCode)orthat he le eaempttherefromand SWNTMINGIVOLELE ALUATION
the basis for the alleged exemption. Any Violation of Section 70315 by any
<�
applicant fare permit subjects the applicant to a civil penalty of not morethan OITILETSSWIT'C �FDCfl1RES aF({
five hundred dollam($500).
6;as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL LECTR CATESO.F r TYPE CONMUCTION
7< rompenetc.rywilldethe work and lhestructure is not intended or offered for
O dale(Sec.7044 Btahsea.and Prorated..Code:The Contractors License Law
S$ does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RFS.UNITS
whodce1suchwork hlmseRorthr.ugh hiaownemploym,provided lhatsuch
Improvements are not Intended oroffered("sale.If,however,thebuclding or TOTAL.-
Improvement bsold wilhinoneyoarofmmpletion.the owner-builderwRl have
tf(g hien of proving that he did not build or Improve for purpose ofeate.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Lj;as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7044,Business and Profee .ioCode:
The Cantractor's License Law time not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wthereon,
builds or Improved and who coci
contracts for much ptcjes with a
mp(factor(s)licensed pursuant to the Contractor's License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B k P C for this rcamn
DRAINS FLOOR;ROOF, SANITARY Y_ N_
OUTSIDE FF17S
Owner Date- AREA'GOND.
WORKMAN COMPENSATION DECLARATION RECE PT Y
p SCITOOL TAX Y_ N
F11 hereby affirm a
that I have a rBcomment acam of cment to self-InureFIX'IIIRFS PER TRAP,or• Z' RFO=M
cestBlateofWarkam Compe.atiml.uranaoracertlfled mpythereof(Sec.
3800,lab C.) S GAEA.SYSTEM-1INCA 0IJTLEI5 PARK FEE y N
Policy 8 CAS FA.SYSTEM-0VER 4(FA) RECEFr M
Com any BUILDING DIVISION FEES
Certified copy b—I.Jhd city
CertNed copy V(fled with the city inspection division, GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�
CERTIFICATE OF O(EMPITON FROM WORKERS' GREASE TRAP PAID _
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200717. Date Recd t#
(0)m l tion need not W completed 1(tW permit bfaone hundred dollars
(5100)afy that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify thato the person hework
forwhlahco permitislasted,
I shag not employ any person in any manner ao o become object to the WATER SYSTEM/TREATING Workers Compensation laws of Glifomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ}T. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you
Hshould became subject to the Workers'Compensation provisions ofthe Labor TOTAL
N Code,you must forthwith comply whh uch provlsco.orthb permit shall be
> deemed revoked. BUILDING
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebyafllrmthat there is a construction lending agency forthe perform ELECTRIC FEE
Z ance ofthe workfor which this permit b leued(Sec.3097,Civ.C.) TOTAL: 3DD pip(� O Lender's Name PLUMBING FEE
34—IL F Iander.Addrce QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I atifythatl have reacithdsapplkatlonand statethat theaboveiramoation
iscOrrect.I agree to comply with all city and county ordinances and elate laws PERMITISSUANCE FEES PAID:
>_ IL refatingtobulldingm.tructcon,and hereby authorize representatives ofthl.
H N cityuenterupon the above-mentioned property for d.pendon purposes. ALTERORADDTOMECH.
Z (We)agree to cave,Indemodlyan d keep harmless the City of Cupertino Date Re ei t#
V
against ldabillaes,judgments,cossand expenaeswhlch may lnenywayaccrue AIR HANDLING UNIT(rO 10,000CFM) SUBTOTAL:
against mid City in consequence of the granting of this permit. AIR HANDLING UNIT(OVER 10,OWCPM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date ExHAus r HooD(w/DUCT) CONSTRUCTION TAX PAID:
- HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or hand le haeardous HEATING UNIT(TO 100,000 BTI) Date ReCel t#
material as cleared by the Cupertino Municipal Code,Chapter 9.1 Z and the
Health and Safety Cale Se tion 75531(a)7 HEATING UNIT(OVER 100,000)BTU) t M IAL:
my. , Na
Will the applicant furore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS
DA'Z'E
which emit harardous air coria mirants ass def red by the Bay Area Air [BAR & 195U
Quality Management District? BOILER-COMP QHP OR 100,000 BM❑yesNo
I have read the hmliTous materials requirements under Chapter 6.95 of BOILER.COMP(OVEt 10),000 BTU)
the California Health k Safety Code,Sectio.25505,25M and 75534.I
understand that if the building does not currently have.tenant,that it is my NEW RESIDENTIAL MEIN. SQFI �RY Of CgDAf�IM
responsibility to r roily the.copse of the requirements which must be nail
Prior to I%u n Of tin w.focccup.rcy.
Owner or authorized agent Date' ISSUEDBy.�
TOTAL:
OFFICE COPY