20253 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFYMT NO.
Buil IA 0
D500
. vt_ z.a BL-VD r 20253
nesse came: one
AL
CITY OF CUPERTINO-BUILDING DIVISION c^
CO tramr'• "1e' 1cT APPLICATION /PERMIT
Sup E�4/'1• C 3 Lic.N BUILDING ELECTRICALPLUMBINGME MCAL CATEGORY CONTROL p
• Amhi /En neer. "1' Lk.No1:0
5� /Issue. BUILDING PERMIT INFO
QTY ELECTRIC PEAMIT FEE ,�.--a�
Address: I PERMITISSUANCE 17y C� ❑ �11Jy� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby dorm that l sum licensed under provisions of Cha pier 9(commene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sc on7000)of DIWMm3ofihe B.M..nd Profession.Code,and my
I
In fu8lo and effect. p PANELS
L.r.
It... a to LIC Y
Date Cantnctrr
ARCHITECTS DECLARATI N 101-IWOAMI'S
x Z I understand my plana shag be used a public records. ' ' OVER UXU AMPS SQ.FT.FLOOR AREA $/SQ.FT.
00
d6 Licensed Professional SIGNS ELECTRICAL
.4�° OWNER-BUILDER DECLARATION SPFGULCIRCUIT/MISE
Zp, ?, Ihembyaf@mttlamexemptfermthe Contractors License Tawforthe _
following reason.(Section 70315,Business and Professions Code:An tl or
FF' county which requires a permit to construct,alter,Improve,demolith,ormpalr TEMP.METEROR POLE INST.
anysuucturepnor Wits Wuance,elsorequlrestheapplicam forsuch permit to POWER DEVICES
file a signed statement the he la Ilmosed pursuant to the prevbbns of the
0w� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi-30 VALUATION eton3ofthelluslnb....d P.9.1maCode)mthat he ext there(romand SWBdMINGlA70L ELECTRIC
g the basis for the alleged exemption. Any violation of Section 70315 by anyLA
<X applicant for a permit subject the applicant to a civil penalty d not more than EISSWITCHESFIX'NRES J4A
five hundred dollars 1$500.
,as owner of the roe NEW RESIDENTIAL ELECTRSQFT. STORIES TYPECONSIRUCTION
7 6 ❑IP P rty,or my employees with wage as there dole
mmpensatlon,wllldo the and structure is intended or offered for
O rale(Sec.7044 Business and Profession Code;The Contractors Liense Law
$$ does not apply to an owner of pmperty who Wilds or Improve thereon,and OCC,GROW RFS.UNITS
whodoessuchworkhimselforthmugh hlsownemployees,provided that such
Improvements are not intended oroffered for sale.1(,however,thebuliding or TOTAL: IOa
Improvementbsold withinoneyearofcompidlon,theowner-b ilderMll have
t rden of proving that he did not build or improve for purpose of sale.).
LCITY. PLUMBING PERMIT FEE FLOOD ZONE APNI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors m constrain the project(Sec.7044,Business and ProfessionsCode:
The Contractor's License Law does not apply to an owner d property who ALTER-DRAIN&VENT-WATER(EA)builds or Improve@ therens,and who contracts for such projects with s FEE SUMMARY
@Antis)licensed pursuant to the Contractor's Lienee Law. BACKFLOW PROTECT.DEVICE
I am exempt under Sec B h P C for this reason
FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N OUTSIDE
Owner Date 'IPT
WORK MAN COMPENSATION DECLARATION
[—]I hereby affirm that I have a certificate of consent to rlf-Insurc,.or a FDn URES PER•TRECERAP SCHOOL TAX Y NRECEIPT X
cenificatesfWorkers'Compensatlonlnsurane or a cergbd copythereof(See. GAS RA.SYSTEM-1 WCAOUTLET'S PARKFEE Y N
3800,Lab CJ f b �A1 RECEIPT M
PoI1ryM P IBS 79 Q�T GAS EA.SYSr M-OVER 4(EA) BUILDING DIVISION FEES
Com any
CCenBl cop filed
the
ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�RErtIRed copy V filed with the tlty Inspection dlvlclon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.IOOFT. Date Remi t#
(This section need net be completed if the permit la forone hundred dollars
($100°rless.) WATQtIiEATFR W/VENT/ELECTR ENERGY FEE Y N
performance o,mlythat In the perfounof the work forwhich this permit is Issued,
1 shall not employ any person In any manner w an to become subject to the WATER SYS.IEM/TREATING
Workers'Compensation Laws of California. Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recti t#
Z NOTICETO APPLICANT:If after making this Certificate of Exemption,you _
should become subject to the Worl,ere'Compensatlon provisions°(the Labor TOTAL:
N Code,you at forthwith comply with such pro Tomo rihb permltshall beBU
EE
W > deemed revoked. '
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Z Iherebyaffirm Nzt there b a construction lending agency for the perform- TOTAL: ELECTRIC FEE r�
e of the work for which this permit is Issued(See.3097,Civ.C.)
an
O O Landers No PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Ienifythatl have read thbapplicatlonand eatethattheaboveinformation
6 Incorrect lagreetocomplywilh allcityand countyonimancesand Mate laws PERMITLSSUANCE FEES PAID:
1_ relating to building constmction,and hemby authotlza representative of this
HN city to enter upon the above-mentioned property for Inspection purposes. ALTERORAODTO MUCH.
? (We)agree to save,Indemnify an d keep harmless the City of Cuper Ino Date ReCCila[#
V against liabilities,judgments,mice and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
age Wt said City In consequence of the granting of this permit AIR HANDLING UNIT(OVER 10,0D0 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date IXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fu n,building occupant store or handle hazardous HFATING UNIT(TO 100,000 BTU) Date Recti t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Ilcalth and Safety Code Sectlon 25531(.)7 HEATING UNIT(OVER IW,"BTUs TOTAL: �4
qI—I Yes M No
Illtheappliant orfulure Wilding occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haeardoua air contaminants as defined by the Bay Area Air
Quality Management DNA&? BOMER-COMP(3FI'OR 100,000 BTU)
Yes ❑No
have read the baurdoud rwterlab requirements under Chaplet 6.95 of BOILER-COMP(OVQ2I W00
, 0 BTU)
the Olifmla FlealthASa(etyCode,Sectlons25505,75533 and 755M.I sr Q IeJ.�i.l
understand that if the building does not mrmntly have @tenant,thatltlamy NEW RFSIDEF1TlAL MEGA. SQFf. MAI V
In'
po ibilityto mailytheoceupanto(lherequbemenl,whichnwstbernet -
Prlorto uano of Alfiate of Oc anry.
of raDno
or ,authorized agent if to ISSUED BY
0 6 TOTAL:
OFFICE COPY