24016 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Buildinx Project Identification PENBTNQ, 4 016
BUI1dinR Address:
-
<... 7L?/,
Phone: .
a cmc V�/� 7910-7-0L CITY OF CUPERTINO-BUILDING DIVISION
co�n�tr(,�or'aN APPLICATION it PERMIT `Q [—
_J/ct/I,gQ BUILDING.ELECTR)CAI.PLUMBING CAT[CORY CONTROLp
Archil-en/Engineer. Lk.No: MGCFIAMCAI.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:. cLt�i PLUMB
PERNUTISSUANCE 1:1 1:1• ❑
LICENSED CONTRACTOR'S DECLARATION
[hereby afflrmlhat l amllcensed under powitatersof Chapter 9 immanent APPUANCESREEDENTIAL JOBD ON
ingwith Serlon 7000)of Dlvlslan3ofth lluslnemand ProfeBlonscode,and my -
license Is In full rte d affect `p PANELS ��
License Chss,��Lt.N �9 J /
Date G/r-t /p'ARCH[actor r '�
V//�T�ARCNITECPS ublic6O OVERI0 AMI"' 1
q�+0O lundetatand my Elam shall be used as publlcremrds. OVER 1000 AMPS SQ,FT.FLOOR AREA $/SQ.FT.
Fi Licensed Professional SIGNSELECTRICAL i "' D.
6 OWNER-BUILDER DECLARATION
rn e-1 SPECIALCIRCUIT/MISC
7 �a 1herebyaffinothatIamexemptfromtheContractor'sLicenseLawforthe
7 qqqq following reason.(basion 7031.5,Business and Professions Code:Any city or
E I"' county which requires a permit to construct,alter,Improve,demolish,orrepalr P.M=OR POLE INSf.
a anystmcturepdortoitslsmancgaleomquimatheappllrantforsuchperMtto q �
fG y'a file a signed statement that hlicensed pursuant to the provision of the POWER DEVICE DA
e k T
Xan, Contractor.Lkme
elaw(Chnptm9(commencingwith Sectlm%7000)o(Dlvl- -/
4411 Orn Mesa ofthe Resinand Pro(mbmCode)orthat he is exemptthera(romand SWRAMING IX)OL ELGRestrainsVALUATION
~ 6 5 the basis for the alleged exemption. Any violation of Sectio7031S by any OUTLETSSWITCHES�HXTURES
applicant fora permit subjects the applicant to a civil penalty of not morethan
flue hundred dollars($500). NEW RESIDENTIAL ELF'CTR SQ.FT. STOIUGS TYPE CONSTRUCTION
F-11,as owner of the property,or my employees with wages as their sole
t 7Z compensation,will clothe work,and thestmcture h not intended or offered for
$ - -
�O sale(Sec.7044,Businm and Pe fmlonsCade:The Contractor's License law
I;rj$$ duce notapplywan owner of property who Wilds or Improves themes,and OCC.GROUP RES.UNITS
whodoeesuchworkhlmsclforthmughhlsawnemployees,providedthatmc
Improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL:
improvement Issoldwithin oneyeamfcompldloMtheownenbuilderwill have
itrden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING,PERMIT FEE pLOOp PONE. ppN
1,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7044,Business and Proffessiom Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 6:VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pkojem with •
coyFEE SUMMARY
[Iactor(s)licensed pursuant to the Contractor's License Law.
15l am exempt under Sec B k P C for this reason BACK PLOW PROTFLT.DEVICE OUTSIDE FFrq
Owner Data DRAINS FLOOR RODE,AREA,COND. SANITARY Y N_
RECEIPT N
WORKMAN COMPENSATION DECLARATION EIX.U�I,ER TRAP SCHOOL TAX Y N
herebyffi
1 hereby arm that I issue's certl0nre
tc of to self-Insure,or RECEM N
certificate ofworken'Compematlon Laurance oracertlfied copythereof(Sec. GAS PA.SYSfEM•1 INC.40UTLEIS PARK PEE Y 'N
38(10.Lobb CJ�� DING DT p
Policy N GAS EA.SYSCEM-0VER 4(FA)
Com anv / i BUILDING DIVISION FEE$ '
�Ce11uc copy em (umished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCI-IECK FEE
edlflxd copy is filed with the city Impe Ilan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYF.A. 00PT Date Recej t#
Rss
M1iectlon headna be completed lithe permit V ne(Drohundred -
dollars -
(5100)arlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify that in the performanceaf the work(orwhich this permit Is issued,
I shall not employ any person In'any manner so an to become subject to the WATER SYSTEM/TREATING
Workerc'Compensa/lon laws of California. Date PAID
OZ Applicant < NEW RESIDENTIAL PLMB._SQFT. Date Remi t# ,
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workem'Compewtlon provlslom ofthe Labor TOTAL'
U) Code,you moat(ort hwith comply with such pmvisiom or tis b permit shall be BU N
LU j deemed revoked. .
CONSTRUCTION LENDING AGENCY $EI$MIC FEE
CL lherebyaliti that there V a construction lending agency the perform ELECTRIC FEE
= Z ance of the workfor which this permit U Issued(Sec.3097,Ctv.C.) TOTAL:
(, O Lcoder'.Name PLUMBING FEE
U. F lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertllythatl have read this appllcetknand Yate Matthe above lnformatlon
tl Iscomed.I agree to comply wltha8 dtyand county ordinances and Yate laws PERMIT ISSUANCE FEE$PAID:
} relating to building construction,and herebyautheriae representatives ofthls
)— Z construction,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 Cupertino Date Receipt#
V against liabilities,judgments,costs and expenses which may In any way accrue AIR HA LADLING UNIT(TO 10,0)0 CFM) SUBTOTAL:
against old City in pe an grant ing oft hand.
AIR HANDLING UNIT(OVER IO,WO CFM) CONSTRUCTION TAX
Signature of AprpHcam/Contr I ate d EXHAUB't HODD(W/DUCT) . CONSTRUCTION TAX PAID:
I=-,to ATERIALS S C L 0 S U R E
Will the a pplicant or future building ocxupant store or hand le hazardous HEATING UNIT(TO 100,OOD BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER IW M BTU TOTA
❑Yea No -
Willtheapplicantor tare building occupant use equlpment or devices VPNI7LATION PAN(SINGLE RISID). ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lity Ma rugement District? BOILER-COMP DHP OR 100,000 BTU)
❑Yes o No
!have read the hazes, ma matedah requirements under Cha pier 6.95 of BOTLER-COMP(OVER 100,000 BM A B D
the Celifcmla Health k Safety Code,Sect Ions 75505,75533 and 75534.1
and ersta nd that if the build tog doei not currently have a tenant,that It is my NEW RISI DENTIAL MECIi. SQ.FT.
rmponsibil By to notify the occupant of the requirements which mast be met AUG 1(2 19
prior to issuance of a Certificate of Occepanry. e
Owner or authodmd agent Data ISSUED
III4U
TOTAL:
OFFICE COPY