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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES.— USE -RSL POINT PEN ONLY
Building Project ldenHflatlnn
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.CITY OF CUPERTIN BUILDING DNI ON
APPUCAT N / PE -
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BUILDINC•ELEC AI-PLUMBIN - ECl1ANIC
CATEGORY, CONyR07/IIQ�
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Archlted/Engineer. Lie. No:
QTY' - EL RIC P qFEE
BUILDING PERMIT INFO
naarca,:
�X� trl-
' PERMIi ISSUANCEAll.
LENSCONTRACfOR'SDECIN
thereby affirm, that
IamMprovbons..fChaper9 (mmmrnc
Ingwlth SeMon700D)ofDlWaon3.fthe Buslnessand Pro(esslonaCodq and my
license is In full force and effect. -
CESRFSID
]Oct DESCRI'HON
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TLS '
P
License Cha® LIc.N
Date - ContractorTP
AW
TO
r
201-IOOOAMM
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ARCHITECTS DECLARATION
Iunderstandmyplavehallbeueedupubli,..N..
OVERT AM
SQ. FT. FLOOR AREA.
S/SQ, FT.
NSEL A
Licensed Professional
OWNEReBUILDER DECLARATION
Ihcrebya(OmnOutlameBUILD R DECLARATION
Lianas Law far the
I A
'v
IALCIRC /MISC
TFMCM ORPOLEINST.
following reason. (Section 70315, Bu.moss.nd Pro(eal.ns Code: Any city.,
county which requires a perm0 toconstrutt, alter, Improve, demolxh,orrepalr
I
B`_
anystmdurepdorwiabodance,aborequimtheappbuntfwsuchperMtto
file a signed statement that he Is licensed pursuant to the pmvbloru of the
ContraRorsLicense Law (Chapter 9(commencing with Section 7000) of Dlvl-
sion 3 of the Business and Profnokma Code) or that he x exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7MIS by any
applicant for a permit subjects the applicant to a civil penalty of not more than
(OWER CLS
-
,esji
SWIM14NG IDOL ELECTRIC
OUTLETSSWITCHMFIXT(IRES -
VALUATIO
five F11, as ownered of tha. e
owner.(the property,., my employers with wages as thele dole
pr.
NEW RESID=AL ELEGTR SQ,FE•
STORIES
TYPE CONSTRUCTION
compensation, windethe work, the s is eme: eLaw
_
�)
(Sec.7044Codhum
cele (Sec. 7044, Business and Pro(enlore Code: The Contadofa Llanse law
rodensThe uact.do License
ra
docs not apply to an owner of property who builds or improves thereon,and
whodoessuchwork himself orthrough hlsawnemployees, provided that such
OCC. GROUT' -
RES UNITS
Improvemern are not Intended proffered f.rsaie. IL howeveq thebullding w
Improvement bsold within omyearofcomplctiogtheowner-bufiderwlll have
-
tryam rdenof proving that he did notbulldorimproveforpurposeofule,),
LJ L as owner of the property, am exclusively contracting with licensed
rentractms tomnsimct the project(Sm.7044, Busineaand Prorado.Code:
QTY, - PLUMBING PERMIT FEE
PERMIT ISSUANCE'-
FLOOD TONE
APN
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(o)em with'a
cgaJra-orta)Bernard pursuant to the Contractor's License Law,
lJ I am vempt under Sec. B & P C for this rcwn
a
ALTER -DRAIN VENT,. WATER (EA)
-FEE'SUMMARY
BAIX FLOW PROTECT. DEVICE
DRAINS F7.00
FIXTURES. PER jTE
GAS FA �,
ARY Y N
RFiCEET N
SCIIOOLIAX Y N _
RECEIPTN
FEE Y N
Owner Data
WORKMAN COMPENSATION DECLARATION
Of hereby affirm that I have a certificate of consent to self -insure, or a
mN(Iaof Workers'Compevatl.nlnsurana ova artl(brl mpy lhercof (Sec.
3800,lle Labb CJ
Pollry N
RECEIPT M '
GAS EA. SYSTIN-0 )Co
GREASE/I USTRL WASTE IN=— R
ING DIVISION FEES
LA -IECIC FEE
'
Cerifled copy is hereby with the
Cerifled copy b filed with the city Inspection division.
CERTIFICATE OF FSEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhxeectlon need not W completed If pertNt b (Drone hundred dollars
GREASE'IRAP
PAID"'t �7Jc•�1cL�,q�b
-t e Recei t#
Dat
SEWER -SANITARY -STORM F.A. 20OFT. y
WATER HEATER W/VFM/EI.ECTR
ENERGYFEE Y N —
r -s ry��,y
PAI D I -Lk
($100).'len.) -
I certify that m the pedormana of the work for which this permit is Issued,
I shall not employ any person In any manner so as to become mrbjed to the
Worker' Compensation Laws of Californx. Date
WATER SYSTCM/•fRFA.17NG
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption. you
should become subpet to the Workers'Compe,natlon Provides of the Labor`e,
Date Recei t#
NEW RESIDENTIAL PLMIL SQI•T.
TOT
Code, you must forthwith comply with such provisions orthls permits hall be
deemed revoked.
ILDING FEEB
SEISMIC FE •
CONSTRUCTION LENDING AGENCY
Iherebyaftlmtehat there be construction lending agency for the perform.
of work for which this permit Issued (Sec. 3097, Civ. QELECTRIC
ana b W
p �r
FEE mil
-
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
Lender'. Name
Lender's Address
I cedifylhatl have read this application and satethat theabovexformatlon
Iscormd.I agreeto comply with all city and county ordinances and sate laws
MECHANICAL FEE
PERMIT ISSUANCE
FEESPAID: •.
relating to building comtructi°n, and hereby.whorfa represenatives of tM.
city to enter upon the above•mentioned property for Inspection purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
a st llabllltlfs, jed mens, mrteand evpenxd wM1lch may In anyway seems
a said Iy c quenmotthe doting.(this nnit
_�
Date' Receipt#
ALTER OR ADDTO MECH.
AIR I IANDLING UNIT (TO 10,000 CIM)
SUBTOTAL'
AIR HANDLING UNIT (OVER 10,000C)
FM
CONSTRUCTION TAX
tum of Applicant/Contractor
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UMT(TO 100,000BTU)
WllltheappBeam or future bullding occupant store or handle hazardous
materlalude0ned by the Cupertino MurddpalCMc Chapter9.IZ.nd the
Health and Safety Code Section 25532x)7
O Yes r] No
Date Recei _
TO I t
HEATING UMT(OVER 100,000 BTU)
'
VENTILATION FAN( SINGLE RESID)
ISSUANCE DATE
A ,a fk,
a`4 V
Will the applicant or future building occupant use equipment ordevlcos
which emit haardous air comamiwnts as defined by the Bay Arca Air
Quality Management Distd07
j'j Yrs C❑ No
'`shave rcadtheFazardoue nuterI.Ismqui. ., unde,Ch.pt,r6.95.f
BOMER-COMP 0HPOR 100,000 BTU)
BOILER-COMP(OVER100,000611J)
the Cali(orna Health&Safety C.de,&di.w 25505,25533and25534. I
A
AUG
_
NEWRESIDENTIALMEC L 'SQ.ET
understand that lithe Wilding does not currently have a tenant, that It b my
_
reopoatbility to notify the occupant of the requirements which =at be mot
Pd.' to Wce uanofd Certificate of Occupanry.
ch -Ir or wre7y
N
,
ISSUED BY:
Owner or authorized agent Date
- -
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OFFICE COPY.