20167 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building/, ' (042,Project Identification ArVS. ,1 P` TN20167
BuOding Address:
nera and: one:
GH�N� CITY OF CUPERTINO-BUILDING DIVISIONOtO
—
c "ay:R y. APPLICATION /PERMIT V
. Arehitess/En I BIRLDINGELECTRICAI PLUMBINGM HAMCAL CATEGORY CONTROL N
glreer. Llc N.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: BLOG
PERIATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION N
I hereby affirm that l am licensed under provisions of Chapter 9(mmmenc APPMANCFSRESIDENIAL - ]OB DFSCRIPITON
Ingwith Sedtan7OOD)ofOlvisim3ofthe Susi a andPmfessionsCode,and my
Ikenselsla. Lic.N /� /_SSD 91 PANELS C.�NMI�J:y �E Ppb
Llcenee Ckss LION ia10
Date Contractor UPT02DOAMPS
ARChall be used
as p ORATION OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
I p�u0DO AMPS IN
DOZ fundemtond my plan shag 6e need upubuc records /'
E� Llcaread Professional SIGNSELECTRICAL
<6lmn OWNER-BUILDER DECLARATION
�n SPECIAL CIRCUIT/MISC
L„ owingimnarason.(Se tLam31.5,Bexempt froessam the Contractor's Code:Law fort he
is counting reason.iSession motto Business and professions Code:My city p it
O�j. TEMP.M OIII'OLE
F,� county which requbnapermttomntugalter,improve,demoibh,orrepalr
aoystmctum prtartolts issuance,alsorequlreatheapplicant farsuch pcZ1.10 IOWF.R CES
Mile a sign d statement that he k licensd pursuant to the provlelon of the
Ore Contractor's License Lw(Chapter 9(commencing with Section
s„30 nSWIMMIN POOL
don3aftheBuennendProfmianCMe)orthetheeeumptt=af d CTRL
VALUATION
the bask for the alleged exemption. Any violation of Section 70315 by any OU LE S
applicant fora permit subjects the applicant to a civil penalty a not momTthanALnfw / of JN
five hundred dollars%500). NEW RESID AL ELEWRSTORIES 7YPE CONSTRUCTION
�a ❑I,as owner of the property,or my employees with wages as their sok
C c mpeneallon,wllidothe work andtheatmaureknot imanddor offend for
Osale(So.7144.Bu.1maa and Professions Code:The Contractors Limnde law
does not apply to an owner of property who builds orimprovesthemonand OCC.GROUP RES.UNITS
0.0. who doessuch work himselfurthrough Me own employees,provided that such
Improvements are not Intended oroffered tarsale.If,however,thebullding or TOTAL:
bnpmvementksddwithnoMyearofcompktlorytheowner-budderwlil have
the)lurden of pmving that he did not build or improve for purpose of sole.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
[_J I,as owner of the property,am exclusively contracting with licensed
mrdmd..to mnlruct the project(Sm 70"Businessad Professlord Code: PERMIT ISSUANCE
The Contractor's License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
bu1Ms or Improves thereon,and who metncm for such pio)ects with a - FEE SUMMARY
ed.r(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
6c I am exempt under Sec. B&P C for this reason
OUTSIDE RES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date - RECEIPT If
•, WORKMAN COMPENSATION DECLARATION PER TROs SCHOOL TAX Y N_
01 hereby ff rm mrti
that I have a Rau
te of consent to self-Inure,or• FOC•IVRFS RFL 4PT X
certificate of Workers Compemalon Insurance me certified copy thereof(Sec. GASYSTEM-1 INC.40UTLE'1'S PARK FFR Y N
Policy
# CJ S F.A. RECEIPTX
Policy N GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cam any
�Certlfied copy k herebyfurnished.the city CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
Ccrtllld ropy Is filed with the city inspection division.
CERTIFICATE OF IJ(E'M PTION FROM WORKERS' GREASE TRA' PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200FI. Date Recei t#
(Thlssectlon ned not be completd B the perm¢k forum hundred dollars
(Slro)orlcas.) WATER HATER w/VENT/ELGCTR ENERGY FEE Y N
I artlfythat ht the performance of the work forwhich this permit is issued,
I she not employ any,Perron In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Tawe of California.Date PAID
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0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Reset Hf
Z NOTICE TO APPLICANT:[(,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisiord of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthk Parma&hall be BUILDING ,
EE
W 7 deemed revoked. ,
CONSTRUCTION LENDING AGENCY EISMIC FEE
0. Ihereby affim"hat there is a msstuctlon lending agency for the perform TOTAL: ELECTRIC FEE
M 2 anreofthe workforwhkhthis permit Let kud elec.3097,CIv.C3
V O Lender.Name PLUMBING FEE
IL — Lender's Addre.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IcarHrythat l hawreadthk application and state thattheabovelnfomutlon FEESMECHANICAL
C #correct.l agresto comply with au city end county ordinances and state laws PERMIT ISSUANCE
} W reldlag tobullding construction,and tructioconstruction,and hereby authorrepresentatives of this
Z city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to sawn indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against lkbWOes,judgments,cosmand expenses which may In anywayacme AR HANDLING UNIT CTO 10,100 CFM) I SUBTOTAL: 7 .
against said City Ina the Ii di ofk.permit.
rrrG 10L ea AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Appll t/ oro Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haxardom HEATING UNIT(TO 100,000 BTI) Date Recei t#
material as deRead by the Cupertino Municipal Code,Chapter 9.11,and the
Health and Safety Cde Session 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ye, Si
No
Will the applicant m building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE '
which emit hawrdous air contaminants as defined by the Bay Area Air PAID Quality Management D 1&7 BOILER-COMP OHPOR 100,000 BTI) P ID
Yca- No
4hawe read eatha oils mater,Se requirementsunderand 25534.
of OOILER-CAMP(OVQt 100,000 B77n :JUty l ►`Jyu
the erstaCalifornia at If
&Safety Code,Sect ions 15505,have
.t and 25536.I
understand that lftM1ebuilding does not currently have atenan4 that ltkmy NEW RESIDENTIAL METH. SQ.FT.
responsibility to notify the occupant of therequlrementsvv h y�st
prior to issue Ice of 17Rcapa cy. ss`"(,/ City,of Cupertino
� s
Omer or authosixed agftt Data TOTAL, ISSUED BY: G vCC..
OFFICE COPY