24126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Protect Identification
BuFid"TN¢ 412 6
la4Building Addrtre: Z
one:
ams CITY OF CUPERTINO-BUILDING DIVISION ry 1)
cmntnnorawme: le. APPLICATION I PERMITNML
Q - UpAq BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Arohitsci/ glmer. Ll.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add PNAI7T ISSUANCE IK�' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION LCfr
I hereby h,%dio 7DOO)rce t l am Bc 3.fsed!hit He d provisions,. dmff h mss odmm d m APPLIANCES-RESIDENTIAL , ` JOB DRI HON�
Ngwmi.i.fullfi cearcl Naon3.'(the Bugncseand ProtesaansCode,andm V\rj� 1tla`..W\WII11
Ilcensa is In fuB force and dfect. PANELS r
Licen Lk M Sur
ate Contractor
ARCHITECTS DECLARATION 201-IODO AMT'S
lo+�9O pZ Iunde and ewpttu shall be used as public records. OVERIODOAMPS SQ.Fr.FLOOR AREA
E (/ Licensed Pmfeselonal SIGNS ELECTRICAL
dddd FE`A� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
XreasonIhenbyaffi.thatlamexempifromthe Contnnor's Limnx Lwforthe
qqqq following .(Section 70315,Business and Professions Code:My city or
FQ muntywhlchre"imsaper ttomtutrun,alter,Impmv demiWh,orrepair TEMP.MEIR OR POLE INS,.
anyatmmmpr rtoltelsmance,alsorryulrestheappHuntfmsuchpemdtlo POWER DEVICES
file a signed statement that he t Licensed pursuant to the provisions of the
Contractor's License law rofingionChapter 9 C od0orthet with hels xamp"he00ot and VALUATION
�
�Oa Cmdrat.e. i.
License
and ProfesskroCmde)olizin with
n7000(romand SWARMING FOOL ELECTRIC tltl1IDD�,
....77771 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURES
<'e
applicant form permit subjenstheappllcant tos civil penalty of not more than
flue hundreddollarsof thepro NEW RESIDENTIAL ELECTR SQ.FT. STONES TYPECONSTRUCTION
I,as owner of the property,or myt employees with ween as thele sole
t 7 a compens70Kation,Business andwill do the rand the sC de:The C ntraIntecdedtor or License
d for
Law
$ O sale(Sec. pply to alnessandf property
Code:The Contractors hemon Law
� does not whodersuch torn owner of1preaugh isonempds orimproves ovidedthatand OCC.GROUP - RES.UNITS
whodaementsa not
mothered
formic.
If,yees,owe er,thedthatau or
Improvements arewtIntendne Year fc krsale.ILhowever, deer ldkgve TOTAL:
Improvement twld within.'neyearolcomplakn,the owner-builderwtll have
the burden of proving that he did not build or improve for purpose allude.). QT•y, PLUMBING PERMIT FEE FLOOD TUNE APN
u L as owner of the property,am exchulvaly contracting with licensed PERMIT ISSUANCE
contractors to cowtmn the project(Sec.7044,Business and Profasalom Code:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN 4 VFM-WATER(EA)
builds or Improves thereon,and who contracts (or much pwocimi with a
ryR([anor(a)licensed pursuant to the Contractor's License Law. gACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec B k P C for this reasonOUTSIDE FEES
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
` Dae RFf_EB'f M
WORKMAN I have aNSATION DECLARATION FIXTURES PER.TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o !mum to of consent to pythsure,m . RECEPT'a
3800,Lcedifiab of Worken'Compematlonituurance.'ra cegBkd copy there.'!(Sec. GAS EA.SYSLEM•l INCAOIITLEI'S PARK FEE Y_ N
C' 3800,Lab CJ
I'ollry tl GAS G.SYSTEM-OVER d(FA)' RFGEI'T X
Com any BUILDING DIVISION FEES
OC.dUcitifiedmpytfil hereby furnished. GREASE/INDUSRRL WASTE INTERCEPTOR PLANCHECKFEE
CerlBied copy tilled with the dtyIwpMlon divigon. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM EA 200FT Date\- Rece{ t#
(Chtsenlon need rat becomplaed Ithe permit t(mooe huntlred dollar
(a1I cnilyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Icertifythat ictus performance of Rha wmk f.'rwNchiMa pemdetiuved,
I Quill not employ any permit In any manner ro as to become subject to the WATER SYSTEM/TREATING
workenv
'CompenioALmwsof California.Date PAID
-
zZ Applicant Date Recei t#
Z D NOTICE TO APPLICANT:If,ager making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. 'y3.Fr.
should become subject to the Workers'Compensation provtkru of the Labor TOTA
N Code,you at forthwith comply with such provlaom ortht permit shall be
W j deemedrevoked. I NEEF
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE -
I hereby afflrmthat there t a commictlon kndingageory for the perform ELECTRIC FEE
Z arm ofthe work!.',which this permit Is noted(Sr,3097,Civ.C.) TOTAL:
V O Lenders Name PLUMBING FEE
LL ~ Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedl(ythatl haveread tidsapp0otlonand gatelha thesisovekkrmatlon
t cormn.I agreeto comply with all cityand county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
U) relating to building congroctlon,and hereby authorize representtives oftht ,
F N city to enter upon the abovcmentloned property for Impectlon purposes. ALTER OR ADDTO MECH.
? (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Recei t#
V agaWt liabWtks,judgment,cogs and expenses which may in anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit
�E- X,_19_ Z ATR HANDLING UNIT(OVER 10,000CFW CONSTRUCTION TAX
Sig-nature of Applicant/Contractor c pate EXHAUST HOOD N/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrdous HEATING UNIT(TO 100,000 BM pate Recei
material as deBoed by the Cupertino Municipal Code,Chapter 9.11,and the
I leahh and Safety Code Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yes Ir�—,I No
WWtheapplieant opium building occupant use equipment ordevlcea VENTILATION FAN(SINGLE MID) ISSUANCE DATE '
which roil haaaedous air contmornme as defined by the Bay Area At,
Q+ Ilty Matugencet DtMcit BOILER-COMP OHPOR 100,000 BTU)
❑Yes No
Ihave read the b.gus materials requirements under Chapter6.95 of BORER-COMP(OVER 100,000 BM
the California Health k Safely Code,SectTmu 25505,25533 and 25531.1 l�
understand that lfthebulldlng does not currently have a tenant that itis my NEWRESIDFNTALMECH. SQ.FT VA B p�
rvponabllityu,nmti/y the occupant of the nv(uleementewhich must be met V
prim to issuance of aCcrtifimkof0ccvpanry. - /)U
Owner or authmived agent Data
TOTAL: ISSIIf[a'jy!
' r• I/VI
OFFICE COPY