21645` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proea Identification /� PERNBT NO.
Budding Address: Lr/ i�o 21645
Z,56'-5360 CITY OF CUPERTINO-BUILDING DIVISION
cot n° ,Nan fan Lic.No: APPLICATION I PERMIT
BUILDINGELECTRICAI PLUMBINGMECH MCAL CATEC'ORY CONTROL N
Aechikct/Englecen Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address
PERMIT ISSUANCE I�I ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION �f
Ihereby
ectionmthat lamheensedl 9=3ofunder provisions Pre Chains ode,and APPLIANCESRESIDENTNL JOB DFSCAIPfION
Ingweh in full
forces Dlvfect. flhe BuslmssandProlessionsCode,and yl_
Lien x is
In full!orae and effect. PANELS v1•T�
Linnse Chn effect.p
Date Cordractor UP TO 2DOAMPS
ARCHITECTS DECLARATION 301-I000 AMPS
DCOC I understand my plane shallbe used n public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
U Licensed Professional SIGNS ELECTRICAL
�4 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC
z f., a Iherebyaffirm that l am exemptfrmnthe Contractor's License law for the
following reason.(Section 7031.5,Business and Professions Code:Any city or
O TEMP.METFR ORPOLE[NSf.
p4 rountywhiN requbnaperMttoronstuct,aller,lmprove,demolbh,orrepalr
anystructure prior to ltsissuance,also requlrealheapplicant fursuch permit to POWER DEVICES
r file a signed statement that he is licensed pursuant to the provisions of the et
3w� Contractors License La-lChapter9(commencing with Section 7000).1 Dlei- yyVLHNBVV
NC POOL ELECTRIC
�Og slnn3 ofthe Business and Profeselore Code)orthat he bexempt therefromand VALUATIgYp
O the basis for the alleged exemption. Any violation of Section 70315 ES
by any OUTLETSSWITCHFTXTURES `06
applicant fora permit subjecbthe applicant to a civil penalty of not more than J
fl�hyndred dallan($500). NEW RESIDENTIAL ELEC7R SQFC. STORIES TYPECONSTRUCTION
7< E�rT as owner of the property,or my employees with wages as their sole
X esation,will do the work and thestrucene 1,not Intended or offered for
.p sale(Sec.7064,Business and Profession,Code:The Contnct.e.Llmnse Law
S$ does not apply to an owner of property who Wilde or Improves Ihemon,and OCC.GROUP RES UNITS
who does such work himeelfor through Ms own employees,provided that such
Improvereents are not Intended oroffered forsale.If,however,thebuildingor TOTAL:
Improvement bsold within oneyesrof completion,the owner-W Ilder will have
Orden of proving that he did not Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
FLOOD TONE APN
L as owner tr the property,am exclusively Business
ess noting with licensed PERMIT ISSUANCE
rontncinnct mnstuct the project(See.app[Businessand of
Code:
The Contractors estisLicense Lw dm not apply to of owner of Property who ALS-DRAIN A VENT-WATER RN
Wilds or improves thereon, and who mntrar's Tic such plojecb with
INctor(a)Bossed pursuant to the Contractor's License Law. FEE SUMMARY
am exempt under Sec B A P C for thio reawn BAIX FLOW PROTECT.DEVICE OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,CONE.' SANITARY Y N
Owner Date RECEIPT
a WORKMAN COMPENSATION DECLARATION SCHOOL 7A% Y N
❑1 hereby affirm that I have a ornificate of consent to self-Insure,ora FI%TURES PER TRAP RECEIPT N
mrtlficate of Worken'ComperwUon lnsunnmora certified copy thereof(Sec. GAS EA.SYSTEM-1 INC OUTLETS PARK FEE Y N
3BE0, Ab CJ R— NECEIPT a
Policy N GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
Cert Riedropyicherebyfumishd. CREASE/WDUSTRL WASIEINTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GRE-ASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F1• Date Recei tin
(This section need nm ba completed lithe permit is for one hundred dollars
($10E)orI..) 1YA.1.p3H�rQaW/ypN.I./D.t>rTR ENERGY FEE Y N
Issued,I certifythat in the performance of thework forwhich this permit is Issued,
I shall net employ any person he any manner so as to become subject to the WATER SYSTEM/TREATING
Worken'Compeneatloo laws.(California.Date PAID
C1 Z Applicant NEIV RESIDENTIAL PLMB. SQ.FT. Date Recei tU
Z O NOTICE TO APPLICANT.If,after making thin Certificate of Exemption,you
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
tl3 Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE ex"
LU `J deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hereby affirm that there 0 a construction lending agency for the perform ELECTRIC FEE
7 O-secs oftheworRf.rwhkhthbpermiti. roe (See3097,CIv.CJ TOTAL:
Lender's Name PLUMBING FEE
U. H Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW isrovIredlfy that have mad this application and state thatlheaboveinformatlon
R ect.l agreeto comply with all city and rounlyardlnancesand slalelaws PERMIT ISSUANCE FEES PAID:
r N relating tobuilding consluction,and herebyauthorlu repmaentativeaafthb
cityto enterupon the aWvemendoned propertyfor inspection ALTER ORADDTO MBCH.
~ (We)agree to save,indemnify an d eemless the City of Cupertino Date Recei t#
V
against liabilities,Istlyramm,cosband expenses whicheraylnanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
nst aid CityN n Amo(the gmetie..fthispennl
S /j AIR HANDLINGUNTf(OVER 10,000CFM) CONSTRUCTION TAX
of Applicant/Contractor le EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC SURE
Will the applicant orfuture building occupant store or hand le hazardous HEATING UNIT(TO 101pD0 BM Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code S%".25532(a)? HEATING UNIT(OVER 700,000 BM TOTAL:
❑Ye No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardous air cents minarts as defined by the Buy Area Air
Qua Illy ManagementD W BOILER-COMP OHP OR 100,000 BM
Yrs o p
Ihav amMus the haus materials requlreemnb under Chapter 6.95 of BOILER-COMP(OVQi 100 aw BM r
the Callfomin Health k Safety Code,Sections 25505,75533 and 25534.1 Y
understand that If tify hlding don not erequiyhannt. hI that It is my NEW RESIDENTIAL MICA. SQFf 44
4y
rcdersta d that
notify it occupant n the m ntly have
whit must met Ip,H
EF
o 11.ofa a ateyfOttvpanry.
s s 9z
ner or author sad agent ate ISSUED BYIT[n/avis
TOTAL;
OFFICE COPY