21025 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Oulldhoa Proen ldentlficatlan PERMIT NO.
Bwm Addreu 2"K zs3 21025
neve ame; one: APP1JCAT0Fl3lJMMrrn A
can ""•"'•` —MAA rAASv^rq CITY OF CUPERTINO-BUILDING DIVISION QII �;Iqc
APPLICATION /PERMIT
• BUILDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROLM
A.m./Engineer. Lle No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address b v SJ PERITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION f
I hereby affirm that l am licensed under provistamo(Chapter 9(mmmen APPLIANCESRESIDENTiAL �^ JOB DESCRIPTION -
IngwlthSectlon7000)of DiW.i=3.(the Businnsand Profes ..'eCnde,andmy
license is firf. .It PANELS ` ( ' �`
turn C o' '($Lie p \K/
DateoY,_ �Contractor (/Ia/
III• ARCHITECT' as public
TION r 1 OVERIEVI)AM
1Q±�0ZOC ]understand my pbnsehaB be used upubacremrds OVER]WO AMPS SQ.FT.FLOOR AREA S SQ.FT.
E (/ Licensed Professional SIGNS ELECTRICAL
dddd FLS - OWNER-BUILDER DECLARATION
Iherem m mG
byafBrthat l aexempt frothe nlradm.License law far the grECIALCR2CUIT/
OO followkgme n.(Sediw7RilS,BuslneseaMProfeasbne Code:Mydtyor
02V county which requires a permit to cons0uct,41e1,improve,dendlbh,or repair 1Eti1 ORP(ILIFNIfENN
NSE
SYSI any structure prior to W iduance,also requires the applicant for such permit to
P K 0k a signed statement that he is licenced pu....to the pmWlone of the D
3µ Contractors License Law(Chapter 9(commencing wtth Section 7000)ofD -
1 0 don 3 ofthe Busluess and Profeulons Code).rthat he is exemp"herefrom and G E' - VALUATION
( the basis for the alleged exemption. Any violation of Section 7831,5 by any fA �Os
6mi
� applicantfar•pert subjects the applicant to a civil penalty of not morethan OUTLE HFSFLYFURES fr O O
py live hundred dollars(ISM.
F1I,as owner of the property,or my employees with wages as their sok NEWRAL ELECTR SQ STORIES TYPE CONSTRUCTION
compensation,will do the work and the structum is not Intended or offered for
O sale(Sec.70K Business and Profembv Code:The Cmarad.e.Llceme law
$ does not apply to an owner of property who Wilde or Improves thereon,and
who daresuch work himselfurth.ugh his own employees,provided that such OCC.GROIIP RFS.UNITS
improvements are not intended oroffered forsale.I(howeveq the W Ilding or TOTAL:
Improvement issold within oneyearofcomplelbm the owner-buBderwlll have
tl%.kurden ofpmvingthat he did artWudmimproveforpurpbseofsale.). Q7y, PLUMBING PERMIT FEE FLOOD ZONE APN
L j L as owner of the property,am exclusively contracting with LicensedppRMI•I•I4-UpNCE
co lamt.n to construct the project(Seo.70K Businem ami Profeui.ns Code:
The Contractor's License Taw don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(24Wilds or Improves theomn,and who contnob for sum ch p9o)ewith a
c7lEgadm(s)harmed pursuant to the Contactors License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LJ I am exempt under Sec B&P C for this reaaan
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Dace
WORKMAN COMPENSATION DECLARATION RECEIPT X
FIX,IVRES-PER TRAP SCIdOOL TAX Y— N
❑I hereby.!Tisco that I have• I rti.m a of consent to pythemof or a RECEIPT X
certi0LbC.) orkera'Compewtlonlnsunnaroramrtlfled copythereof(Esc. GAS FA.SYSI7IN-11NCA OUTLETS PARKFEE Y N
' 3800.Lab C.)
Poli p —
AECEI f X
Gm y GAS EA.5YSTFM-0VERdLEA) BUILDING DIVISION FEES
[�CertiOed copybhereby fumlehed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Camfied copy b Bled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF-ASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XpFT• Date Revel tk
(fhb sedlon not be completed if the permit b(w.m hundred dollars
($1I,)HE,
WATER HEATERW/VENT/ELECTR ENERGYFEE Y N
Icertlfy thrt t padomunce of theworkforwNc this cotta ie loved, —
I ahaB no[em y pe Y manner eo u sub' to the WATER SYSTEM/TREATING
Worken'Cam sari..Law (G fomk.Date Q PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQ.Fr. Date Revel tN
Z O NOTICETO 1CAN if,afte dngt eCertlflcateo( xemptlon,you
.hmldbaaomeeubject tot eW II s'ComFooutlan provhloruofthe Ldoor
TOTAL:
CC N Code,yrx..dfadhwRhc npl� aheuch provlclomorthb permit&hall be
7 deemed revoked.
BUILDING00
W
C CONSTRUCTION LENDING AGENCY - SEISMIC FEE
I hereby sflrmthat thereb a comtmctlun lending agencyforthe perform ELECTRIC FEE
:) O anceofthew.rkforwhichthis Forma b Issued(Sec.3097,Clv.C.) TOTAL:
02 Lender.Name PLUMBING FEE
IL 1Rnder's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icartlylhatl have read thisappllcatlonand statethattheabovelnformation
bcorrect.]agree to complywith a adyandmuhmixe anmsand&es.fiws PERMIT ISSUANCE FEE_$Pnl r}jt��O�
} O' ad building constmctim,and hereby autharlu mpmentativn.(this I aJ'
H N city en rupon the above-m 11=property for Inspection purposes. ALTFRORADDTOMECH.
? e)siren to save,indemnify an d keep harmless the City of Cupertino Date Reaei ted
V &gal t Ilitiea,jud n meband expenses which may In anywryamme AIR HANDLING UNIT(TO/0,030 CFM) SUBTOTAL'
ag Id City
segue mol the gcanttag of this pamdt
/'� AIR HANDLING UNIT(OVER IQODOCIM) CONSTRUCTION TAX
Sig.N. Apph t on actor - �/� t EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
H R US MATERIALS DISCLOSUR
Willtheappilnnt re building occupant store or handle hazardous HEATING UNIT(ED 100,000 BM DatC Reeei tit
material as dented by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand Safety Cad fra�S.edlon2SS33(a)7 HEATINGUMT(OVER 100,000BTU) TOTAL
❑Yea L_I Na
Will the applicant orfuture Wildbgoompant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUP-A TE '
which emit havardous air contaminants as defined by the gay Area Air
Quality Management District? BOILER-COMP OHP DR 100,0008'Hn ^^O
4Yes �N. SEP 1 J
havercad Health
ohs materialstions 25505,25533 and
Chapter 6.95 of BOILER-COMP(OVER 1W,000 BTU) JJ
the 'omk Health&Safety Code,not onmttly have
a tend,that i aF�
4ea
that lithe bulldingdon nmcorrcntly have atenanq that ltkmy NEW R6SIDFNTIAL MECH. SQ.Ff. gTX•y aL ire ��I HIIQ
ytond%an
pantoftherequlrementsw Ich at be area Of II H
PHameeof Occupancy. Q•) 1
01 J
uah :iwdale O ISSUED BYJ
TOTAL:
OFFICE COPY