23469 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Bulldin Pmed ldentlficatlon PFitMITNO,
Bu1Wln Addrev: 1 4et+iD 23469
ere r: err'• one CITY OF CUPERTINO-BUILDING DIVISION API'LICAIIONSUHMIIIAL
Contrador'a Name: Lk.No: APPLICATION 1 PERMIT
Architect/Englr,ser. Lie.No: BUILDINGELECTMCAI PLUMBINC-MECHAMCAL CATEGORY CONTROL Y
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addme: POWTISSUANCE � ❑ ❑
LICENSED CONTRAROR'SDECLARATION APPLIANCES-RFADENTIAL affimthat salad of Chapter9(mmmene JOB DESCRIa77O
II...I Section force anDlvifect. fthe Buslmnsand ProfeWoneCode,and my
I reale las force and ic.It PANELS
(.lease Gla® LILY
Data Conliactar
ARCHITECTS DECLARATION 211-1000 AMPS
1Q±�O CZO I understand my plane shall be used as public records. OVER IOOO AMPS SCJ.FT.FLOOR AREA $/SQ.FT.
ELicensed Professiarul SIGNSELEMRICAL
fn 6 OWNER-BUILDER DECLARATION SPECIALCEtCNT/M15C '
H
Iherebyaffirmthall amexempt fromihe Contractor's License Lawforthe
Z o following resume.(Section 70315,Business and Professions Code:My city or
OZ TEMP.METQt ORIOLE INST.
p� muntywhlrh requlrecapermi[tororotruct,ilter,lmpmve,dennWh,orrepalr
aAystructum priorto itsiuuance,also requires;theapp0cant forsuch permit to POWER DEVICES
O e a signed statement that he is Bcensed pursuant to the provisions of the
Contndor'e Llcame Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC� VALUAT7�5 slon3ofthe Business and Pefeseloa Code)mthat he hexempt therefmmand CU
6 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESSHXfURES
applicant for s permit subjects the applicant too civil penalty of net more than
five hundred dolWs($500). NEW RESIDENTIAL ELECTR SQ.FT.
❑I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
mmpensa0on,will do the work and the structure is not Intended or offered for
A asLe(Scc.7044.Business and Profenkne Code:The Contrectoe.License law
$ does not apply to an owner of property who Wilde or Improves thereon,and OCC.GROUP RES.UNITS
EE who docasuchwork himself orthrough hisown employees,provided thatsuch
Improvements are not intended proffered forsale.If,however,thebuilding or TOTAL:
Improvement bsoldwithln oneyorofcomple ion theowner-bullderwUI have
t1ltJlurden of proving that he did cast build or bnprove for purpose ofeale.), QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044.Business and Professions Code: PERMIT ISSUANCEr..
The Contractor's License Law don not apply to an owner of property who AL.)Pg DRAIN&VENT WATER(EAP
Wilds or Improves thereon,and who contracts for such pipieds with a FEE SUMMARY
olapector(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
QllTcInFrVrq
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date - RECEIPT Y
I WORKMAN COMPENSATION DECLARATION SCI{OOL.TAK Y_ N
F11 hereby affirm ce
that I have a rtlficste of consent to self-Nsure,or a FDCH)RES PER TRAP
I mdi(Icateof Workers'Cwnpema anlaumnmor&mAifkdmpythemof(Sec. RECEWT0
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
RECEIPT Y
Pettey M GAS EA.SYSTEM-0VER 4(FA)
Com any BUILDING DIVISION FEES
ffCertified copy is hereby furelshed. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Candied copy is filed with the city inspection division.
CERTIFICATE OF E)(EMPTION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA ZID{rl' Dale Rece( t#
Ohl.sedion need not becompleted lithe permit is forom hundred dollars
(9100)or leu3 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I net
that o any person
an manner
so as to become
em emnit la blued,
I.hill not employ any person In any manner at u m bemca subject to the WATER SYSTEM/TREATING
Workeri Compenutbn Laws o(
California.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQF7. Date Recei tN
Z 0 N0110ETO APPLICANT.If,after making thisCertificateof Exemption,you
should become subject to the Workers Compensation provisions ofthe Labor arm TOTAL:
N Code,you=at forthwith compty with such provisions orthb permit shall be B �•
W j deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 hereby af0m:that there Is a roatrection lading agency for the perform- ELECTRIC FEE
M Z anceeftheworkforwhkhthbpermlthhsued C.c.3097,CIv.C.) TO —s
02 I.racier'.Name PLUMBING FEE
LL F- Lenders Add. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iso m I certlfythatl have madthls appliudonand Amelhattheabove Information
6 et.I agmeto comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} N relating tobullding construction,and hereby authorize on representatiofthis
d to entero n the abovcmentioned propertyfor to ALTER OR ADDTO MECH.
~ ? city
ag ,Indemnify and eeMese the y of uupeM1lno Date Recei tM
V against be a,' amends, nenw Inanywayatvu AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against o sequ of nti it.
AIR HANDLI NG UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
repppuunt/Centnct a Date E)(HAIIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATE ALs ISCLOSURE
Will the applicant orfumm building occupant atom or hand Is harardous HEATING UNIT(TO 100,000 STU) Date Recei tic
rt
merlal as de0ned by the Cupertino Municipal Code,Chapter 9AZ and the -
Health and Safety Cade Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yo No ytlsw
Will the applicant a ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IFOUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PHP OR 100,000 BTU) ) CHH
PYes n No
havenmd theb.m usmaterlala requirementsunder Chapter6.95of BOILFR-CDMP(OVER 100,000 BTU)
the Celffcmia lloalth&SafetyCols,Sectlom 75505,25533 and 75534.1 ^ a7 v
'- understand that lithe building does not currently have a tenant,that itismy. NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirements which at be met -•" �'(ttt)"r
prior to Issuance of a Certificate of Ocuupa nry. Ur vta
l?
Owneror authorizeTOTAL:
d agent Date ISSOEDBY' `a�/rf
OFFICE COPY :