22761 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Profen Identification PIRMITNO.
Building Add ress: J/ 2f") r
Owner a tme: =! one t APPLICA IION SUBMITTALA
IP L CITY OF CUPERTINO-BUILDING DIVISION �^ /i
contra"pr '^. 1 Lic.N. APPLICATION / PERMIT '""�
BUILDING-ELFICTRICALPLIIMBING-MECHAMCAL CATEGORY CONTROL X
Amblteet/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERMITISSUANCE ❑ 1::1nen ❑
LICENSED CONTRACTOR'S DECLARATION LION
I hereby tflinnthat I)ofDi sion3lecrescdueder Busi Lslonsof Chapter9(e,and m- APPLIANCESRESIDENfIAL JOB DF5CR8'110N
Intree is ratan form ofd Wslan3o(theBmluvand ProfesslonaCade,and my
License
le 1.U full force and k.# PANELS
Date CU. Lk.M
Date Contractor
ARCHITECT'S DECLARATION Ml-1000AMPS
p�uoto . Iunderstand my pian shall be used as public records. OVER 1000 AMPS W /SQ.FT.
} Licensed Professional SIGNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPFf1ALCIRCUIT/MISC M P U T E
ZE'�a affirm that hereby athat l am exempt from the Contractor's License law for the
followingreason.
regir(Section
saprmittorcromm and Professions Crrolahytltyor
f'w fountywhkArequlresape7WIS,cosiness ndPnfeed ..lter,irnprove, ode: nycityalr TEMP.MEM OR POLE INST.
;5 l7 anystructure priorto its Issuance,also requLmthe applicant forsuch permit to
POWER DEVICES
co
c file a signed statement that he is hnsed pursuant to the provision of the
Contractor's License Law(Chapter 9(commencin whh Section MD))of Divi.F, OS slon3of the Businessand PrefenlonsCode)orthatt he V exempitherefemand SWIMMING FOOL ELECTRIC VALUATION
basis for the alleged exemption. Any violation of Section 7MIS by any
SOSp
applicant fora mit subjects theapplicant to a civil al anot room than OUTLETSSWITCHCSH%TURES
fPP Per Ipenalty
five hundred dollars(SSM.
�n 1,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR
PRET' STORIES TYPE CONBTRUCTION
pevatkm,wHldo the work andthe structure U not Intended or offered for
O sak(Sec.7016,Bualnessand Pmfesion Code:The Contractors License Law
`5$ does not apply to an owner of property who Wilds or improves themorland OCC.GROUIP RFS.UNITS
lforthr gh Msownemployees,provldMthatwch
Improvements are not Intended proffered for sale.If,however the building or TOTAL:
Improvement6s ldwithinomy arofcomplMioe,theowner-WIlderwillhave
t rden°fpmving that he did not WBdmhnpmvvf.rpurp..fs.lx.L QTY. PLUMBING PERMIT 'E FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with licensed PFRMR ISSUANCE
contractors to construct the project(Sec.7006,Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER[EA)
Wilds or Improves thereon, and who contracts for such ixojeata with a
<�Wfactprt8)homaed Pursuant to the Contra th ri License Law, FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE OIITqln_
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT N
WORKMAN COMPENSATION DECLARATIONSPER TRAP SCIilX1L TAX Y N
QI hereby affirm that I have o certificate of consnt to self there' ora I;CTUW • (�m'T X
corilfisateo(Worken'Comperwtlonfnuranm ora mrti(led copythereof pec. GAS EA.SYSTEM-11NC.O OUTLETS
3800,Isis CJ PARK FEE Y N
PoHry X GAS EA.SYSTEM-OVER 6(FA) RECEIPT'X
^y BUILDING DIVISION FEES
crtlfied copy Hherebyth the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
citified copy V filed with the city Inpe<ion dlWalon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM STORM EA 20OFT Date Reeei t#
(This sMW1pn need not complMed lithe permit N(or pee hundred dollars
($I Imaifyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll nm employ
N the person
n the work fors tob this permit is issued,the —
1 shag not employ an/person it any manner at u to become subject to[h< WATIR SYST M/TREATING
Worken'Compensation Lawsuit Ullfornia.Dace pA1D
O Z Applicant
Z O NOTICE TO APPLICANT:IL after nuking this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Dale Recel t#
Hrsn should become subject to the Workers'Compensation provisioofthe Labor TO-CAL:
CC y Code,you must forthwith comply withsuch provision mthls pemat shall he
W j deemed revoked. BUILDING ELE
CL 0 CONSTRUCTION LF14DING AGENCY SEISMIC FEE
I herebyaffirenthat there U a construction lending agency for the perfomr,
7 Z arace.ftheworkforwhkhthispermitlstsmed(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
02 andereName PLUMBING FEE
IL ! Lenders Address QTY. MECHANICAL PERMIT FEE l MECHANICAL FEE
O W cedifythat l have reacithbappHetlonand statethattheabove Information
1 cscorreM.Iagree tocomply withal)cityand countyordinarms and state laws PERMIT ISSUANCE FEES PAID:
)- W relating to building construction,and hereby authorlu representatives ofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cuperilno Date Receipt#
against HaluHtics,judgments,costs and expenses which may In any way amus AIR HANDLING(IMT CI'O i(L0D0 GEM) SUBTOTAL:
agar \t said Clty In nequenm the gr in f molt, -
AIR HANDWNGUMf(OVER t0,000CM) CONSTRUCTION TAX
Ig u pplloan ontractor Date FXIiAUSr HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcane orfuture building occupant store or handle hazardous HEATINGUNIT(TOIOO,O)OBTU)
material's defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Recel [#
Health and SafMy Cade Section 2532(')7 HEATING UNIT(OVER 108000 BTU) TOTAL: l��(J
T❑�Yes No
Will the °r(utumbullding occupant use equipment or devices $B��rLER-COMP
LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havrdous air rontaminants as defined by the Bay Area Air
'
QualityManagementDisMtt7 OHP OR IMDW BTU)
T Yrs I1 N°
Yes
read the haza pus rateriab rcqulremenh under CM1apter 6.95 ofFCOMP(OVER IOO,000BN)
the California Health h SafelyCode,Sections 25505,25533 and 25534.1 �aR®
understand that lithe building does not currently have a tenant,that it UmyESIDENTIALMECH. SQ.FC PA
JO
to notify the occupant of the requiremems which must be met
prior to Issuance of a Certificate of Occupancy. 5�P u
TOTAL: ,agge
Owner or authorlud agent Date ISSUED OY: V
r.
OFFICE COPY