19782 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
Building Prosect IdentificationPHIMIT NO.
ifullding Addmae. 2b ShIQ �¢ . 19782
_a•-� CITY OF CUPERTINO-BUILDING DIVISION
Ghtracue'.N.mr I LO.No: APPLICATION I PERMIT'
rchlI IP, r. BUILDIrJGELECTMCALk' RING-MECIUMCAL CATEGORY CONTROL#
Llc.No:
QTY ELECPRICPERMIT FEE BUILDING PERMIT INFO
Address: FERh1ITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafflrmthat l am licensed under provisions of Chapter 9(coeumene. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlh Section 7000)oH ion3ofthe Buslnossand ProlnsionaCode,and my
liana Is In(ul died. PANES
Lia C Lic.N
nate Co. ado, — TI IXUP TO 2DO AM
ARCHITECTS DECLARAT10N 201-1000 A.MI5
0Z Iunderstand my plansehall lx used as public records. OVER1000AMPS SQ.FT.FLOOR AREA 6/SQ.FT.
O
a U E Licensed Professional SIGNS ELECTRICAL
G
6 OWNER-BUILDER DECLARATION SPWIALCRCUIT/MISC
Imneby.ffirmflut exemptfirm the Contractor's License Law for the
follntyw reason.(Section 70115,Business and Pro(ealons Code:Any cityor
F au9 auntywhlch requlrnapermictomvtmd,alteglmpmve,dem lWh,ormpalr TFMP.METEt OR POLE INST.
anystmctompriareoib6auance,a6orequimatheapplluntforsuch permitto
O U ilk a signed statement that he 6licensed pursuant toted provisions a( the POWER DEVICES
Contractor',
FSO License
rrofeamis Code)orhe with on
exempt he�rcfmmand SN'0'iMil'`G IDOL ELECTRIC VALUATION
4 a•9.�t the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLE7SSWITCH MX7URPS
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars(f500I. NEW RESIDENTIAL ELECTRSQFI',
SCO TYPE CONSIRLCTION
O? ❑I,as owner of the property,or my employee with wage.as their sole
compensation,will do the work and he structure 6 not Intended or offered for
a O cle(,Sec.70141,Business and Professions Code:The Contractor's Decree Law
p5� does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RES.UNITS
doessuch work himself orthrwgh his own employees,provided that such
Improvements an not Intended oraffered forsale.If,however thebullding or TOTAL:
improvement 6sold wlhinoneycarofcompletion,ted owner-Wilderwill have
ttc,la,rden of proving that he did not bund or Improve for purpose ofsalr.). QTY, PLUMBING PERMIT FEE FLOOD ZONE ArN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to rom
nsact the project(See.70141,Business and Pmfevlov Code:
The Contractors License Law does net apply to an owner a property who ALTER-DRAIN k VENT-WATER(FIs)
Wilda or Improvn thereon, and who comrade for such ptojeda with a ,
LLLLI{actm(s)licensed pursuant to the Contodors License Law, FEE SUMMARY
IN am exempt under Sec B k P C for Ih6 reason BACK FLOW PROTECT.DEVICE
•
DRAINS fl.00R,ROOF,AREA,GOND. SANITARY Y N_Owner Date. RFLEBT N
WORKMAN COMP F3JSATcam DECLARATION FIXTURES FER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that 1 have• Ins.t.to of consent to copy
ora RIX EFF'
certificate of Worken'Compensation lvurance as certified copy hereof(Sec. GAS FA.SYSTEMd INCA OUTLETS PARK FEE Y N
3800,Lb CJ
Policy N RECEIPT N
Com an CAS EA.SYSTEM-0VER6(EA)
Y BUILDING DIVISION FEES
rtlficd copy 6 heed y Itino.hed.with the
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�ertifled ropy6(i�d with ted city Wpedloh division.
CERTIFICATE OF EX EM PITON FROM WORK ERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARYSIORM EA 20OFT Date Recei t#
(1'hlesedion read cad W completed lithe permit 6/or one hundred dollars
(3100)othat
WATER HEATIER W/VENC/ELFGTR ENERGYFEE Y_ N
1 certify not that o the performance aof ny
m wok for which this permit c issued,
I shall not employ any Lava in any stunner n as to become strbjed to the WATER SYSII]A/TREATING
Workers'Compensation Lss�of Glifomia.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFF. Date Recei tic
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should became subject to the Workers'Compewti n provisions of the Labor TOTAL:
SNI Code,you most forthwith comply with such provislons orth6permitpedt shall be BUILDING FEE> deemed raveled.
CLreO CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that then u a construction lending agency for the perform ELECTRIC FEE
()
L) O= area of the work for which this permit 6issued(Sec.3097,CIv.C.) TOTAL:
Lender's Name PLUMBING FEE
LL f- Lender'snddnaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O
W laAifyhdve
twreadhwppuutionand Gafethauheahovelnfumation
6mrred.lagrtrtocomplywihalidtyandmumyonilnanasandstatrlaws / PERMIT ISSUANCE FEES PAID:
R relating to building construction,and hereby authorize representatives ofthb
Z city to enter upon the above-mentloned property for Inspection purposes. ALTER OR ADD TO MECH.aDate Recei IM
aFA— (We)agree to ve,Indemrd(y an d keep harmless the City of Cu pertlno P
Inst llabllltles,Ndgmerd,costs and expenses which may In any way amus NR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL,
aid CBy in consequence of the granting of this permit.
I, AFRI-ANDUNG UNrr rovFR l0000 cFM) CONSTRUCTION TAX
Y,D
ursof Appicant/Contractor Date EXHAUSTHOODIW/DUCT) CONSTRUCTION TAX PAID:
HAPARDOUS MATERIALS DISCLOSURE.
Will the applicant^rfuture building occupant store or handle hanrdous HEATING UNIT(TO 100,ODO BTU) Date Recel tic
material as defined by the Cupertino Municipal Coda Chapter 9.12,and the
Iiealth and Safny Code Scrxion 255324)? HEATING UNIT(OVER I00,0D)BTU) TOTAL:
❑ Yn No
Will the applicant.0tum building occupant use equipment or devices VENTILATION FAN C51NGLE RESID) ISSUANCE DATE
which emit hanrdous air enntamirute sae defined by the Bay Area Air PAM Management anageent District? BOILER-COMP OFR OR 100,000 RTU)
Yn azI�No
have read the ba[2onderia6 requimmems underChapter6.95 of BOILER-COMP(OVEi 1#,000 BTU) (�
the California Health h Safety Code,Sections 25505,25533 and 25536. I !s
understand that If Wm 6
he build Ing does ncurrently have a tenant,that It my NEW REST DENTIAL hfECTL �'T
9Q.FT. )f g V
responsibility to notify the..pant of the myulmments which at be met a '
prior to issuance of a Certificate of Oav pa sty.
Owner or authorized agent Date 1SSUF:DBY: `a�� �1�6�risF�rrt'"r '�'Css
TOTAL,
OFFICE COPY