23807 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed Identification
Building Address:
I oLimL V GAJ
v
CITY OF CUPERTIN66U[LDING DIVISION /e 11�^
Contr. .Nanta: Lic.Nm APPLICATION / PERMIT L
BUILDINGELECTRICALPLUMBING-MECH MCAL CATEGORY CONTROL X
Aahltect/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMI
I'LUMD O
Address: PERbITISSUANCE '�
LICENSED CONTRACTOR'S DECLARATION �a R'pypp.Iy(�
I hereby affrmthat l am licensed under provisions of Chipter9(commara APPLIANCES-RESIDENTIAL JOB D�s+V.'1 �'�"�
IngwlthSMion7000)of Dividon3ofthe BuslnessandPmfe.NonaCode,and my �1.w�
llcenx is In full fora andeffect, PANELS 1
License Clan Lk.X
Date Contactor f
ARCHITECT'S DECLARATION 201-IODOAMPS
�$ I understand my plans shall be used as public mounds. OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.Fr.
Llcenord Profenlanal SIGNS ELECTRICAL ® TL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIXALE N
f, FIN
thereby oft m that i am exempt from the Contractor's License Lw for the
following reason.(Section 7031.5,Business and Professions Code:Any city or TAMP.METEROR POLE[NST. ER
I" ceuntywhlch requires a permit to construct,alter,Improve,deolkh,creepor
q`a anystmmmptkrwilb anaa,abomlulrestheappbmntfwwchper tto POWER DEVICES
L5 file a signed statement that he is licensed pursuant to the provisions of the
60w� Coatroot.e.License Law(Chapter 9(commentlng with Section 7000)of Divi- SWIMMING POOL ELECTRIC DATE VA AI (ja
W O gon 3ofthe Suslnessand Pro(essimu Cade)orthat he bexempttherefromand AA Vy
Sn g the basis for the alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHESFIXTVRES ' OV -a—as
O ,pliant forapermitsubjects the applicant to a civil penalty of not moathan _
ve ndreddollan(E500. NEW RESIDENTIAL ELECTRSQFr. STORIES TYPECONSTRUCTION
I,as owner of the property,or my employees with wages as their sok
7Q c p¢nntlon,wBldolheworkandthestru re is ontudendedmoffeadfor
O este(Sec 7004,Business and Pro(mlam Code:The Contndols License Law
$$ does not apply to an owner of property who Wilde or improves thereon,arid - OCC.CROUP RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended conflicted foraak.11,hmvevegthebulWing or T
Improvement bsold wlthlnoneyearofecmpletion,Ne owner-Wllderwill have
tli,kimien of proving that he did nM Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD BANE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
com, does to construct the pm)m(Sec 7074,Business and limitations,Code:
The Contrachm.License Law does not apply to an Owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ,Rap ft Waita FEE SUMMARY
gqppl1TTador(s)Ilceneed pursuant to the Contractor's License Law. RACK FLOW PROTECT,DEVICE
cIJ I am exempt under Sec. B k P C for this reasonOUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y N
• If
Owner DECLARATION
RFAEI
JVORKIMAN COM SAT[ DEC0.ATION FI%TURES PER TRAP SCHOOL TAX Y N N
❑I hincifyaf(inn that I have•aniB a of concent mself-Inmrc,ora RECEIPT X
certi(iateof, Workers Compematlanlmunnceoracedifled copy thereof(Sec. GAS EA.SYSTEM-i RICA OUTLETS PARK FEE Y N
3800.Lab C.) RECEIPT I
Policy X GAS.P.A.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Cam any
ffMy Red copy b hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy Is filed with the city Inspection division. 2 ���
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE ' SBWFR- STORM EA 200Ff Date Receipt#
(This tonneedoutbecompldcd Ifthepeon,!Isfororohundreddellen
(giro)°rima WATERHEATER W/VENT/F1.ECTR ENERGY FEE Y_ N_
1 eci ifythat lathe performance of the work for which this permit Is issued, ,
I shall not employ any person In any manner w see to become subject to the WATER SYSTEM/TREATING PAID
Workers'CompenuHon Laws of California.Date
—
0 Z Appllant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:[,after making this Certificate of Exemption,you
should become subject to the Workers'Compenaat ion provlslona of the Labor TOTAL:
V9 Code,you must forthwith comply with such provisions or this permit shall be BUI DING FEE
LU lamed rex'nked. SEISMIC FEE
CONSTRUCTION LENDING AGENCY
a Iherebyaffirm that there Is a construction lending agency for the perform. TOTAL: ELECTRIC FEE
Z ance ofthe work forwhlch this permit le Issued(Sec.3097,CIv.CO PLUMBING FEE
V O Lender's No
IL h- Landers Addmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have read thisappliation and statethattheabovelnformaron FEES PAID:
6. incore
rct.Tagreetocomplywlth all cityand countYmilmancesand gate law. PERMIT ISSUANCE
rel.ting to building comtrudion,and hereby auth°dze tepresentativae of this
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTFRORADDTOMECIL Date Recei t#
(We)agree to use,Indemnify an d keep hatinlm w
the City of Cu penl
L.I against liabilities,pdgrents,cods a nd expenses which may in any way same AIR HANDLING UNIT(TO I0,00)CFM) SUBTOTAL:
ag.lmtaxi City In ounsequence oft ha, oil If of this perm ie. CONSTRUCTION TAX
2 '/_ AIR HANDLING UNIT(OVER IO,000CFM)
Ig fAppBam/Contra Dare EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAL RDOUS MATERIALS U LOSURE
Will the applicant or futurebullding orapant tore or handle harardom HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Muhiclpal Cede,Chapter 9.12,and the
I With and Safety Coude Section 25532(.)7 FLOATING UNIT(OVER 100,000 BTU) TOTAL
❑ Yes. No
Wail theapplkaat°r u,u but (S.)ccup.ntuseeq.1p.rct.rd.vias VENTILATION FAN(SINGLE REMTMOTAL;
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
Quality Management Dlstrid2 BOILER-COMP(311POR 100,IXp
❑Yea ❑❑No PAID
]have read the hazarclOus materials requirements under Chapter 6.95 of BORER-COMP(OVER 1ro,Oro B
the Calife.ia Health k SafetyCode,Sections 25505,25533 and 25534.I 7
understand that lithe building Moa not currently have.tenant,that it b my NEW RESIDENTIAL MECH. -JUN
responsibility to notify the Ompant of the requimmots which must be met 1992
prior to issuance of a Certificate of Occupancy.
CITY u•����"���,Yk
Owner or authortred agent Data ISSUEDBY:
OFFICE COPY