22705 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PLRMITNO.
Bonding Add.,: lk� 22705
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lie J v n CITY OF CUPERTIN06UILDINC DIVISION � _ r f rd 1
Cor ctnr �1 �[_ / 1{rP� N�� APPLICATION /PERMIT I 1 1
"G1 �� "�� BUILDINGELECTRICALPLUMBINGMGCHAMCAL CATEGORY CONTROL
• Ah:chitect/Engineer. Lic.No:
Qrr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE (�Q ❑ � [:] O
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffimnthat 0)of iv Bans oftheerp Business and
reChapter9(le,and APPLIANCESRESIDENML JOB DESCRIPDON
togwithin full
force afd died. PANELS ofthe Businesand ProfealonsCode,and my
Llemalelns form and c.N PANELS
License Class Lk.X
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
re 7. I understand rey plansshallbe used a public recoNs OVER 1000 AMPS SQ.FM FLOOR AREA E/SQ.FT.
Licensed Profesiansl SIGNS ELECTRICA "��
a OWNER.BUILDER DECLARATION SPECIALCIRCUIT L�ai-X-i7-4-0D
L, 7 I hereby affirm that l am exempt from the Contractor's License Law for the O�
7�p following reason.(Se cion 7m L5,Business and Profession Code:Any dtyor �g{p MECEft OR I'OL
lriS_i c ntywhkhmqulresaperMttommtmct,alter, pmve,dennlbh,ormpair f-a MI"+s
anystructure prlortolts issuance,also requlrestheappRmnl fersuch permit to POWER DEVICES `�
6 y file a signed statement that he 6 licensed pursuant to the provisions of the
Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING FOOL ELECTRIC
O sion3ofthe Busineaand Profealomu Code)orthahe6emm themfmmand
5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCI-]ESFIXf(1AES .:{ �'
uKK1
applicant fora permit subjects the applicant to a civil penalty of not nnre than
five hundred dollars(S500). NEW RESIDENTIAL ELECIR SQ.FT. STORIES TYPECONSTRUCTION
? ❑1,as owner of the property,or my employees with wages as their sole
coceps.ration,willdathewwkandthestmumu not intendedor offeredfor ox c2
psale(Sec.7044,Business and Profeslons Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon.and OCC.GROUP RES,UNITS
F,S.. who does such work himself or through hisown employers,provided that such
Improvements are not intended oroffered for sale.Khowever,thebuildingre TOTA I
Improvement 6sold withlnone)earofcompldbktheowner-bullderwill have
tl�vof of pmvingthat he did rat build orlmprove for purpose ofeale.), QTY. PLUMBING PERMIT FEE FLOODZONE APN
L 1,a owner of the property,am exclusively contracting with Ilrensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
'Due Contractor.License Law does cot apply to an owner a property who pLTFIt-DRAIN&VENT-WATER ffN
Wilda or Improve thereon,and who contracts for such p4ojects with a FEE SUMMARY
cgft actors)Barnard pursuant to the Contractor's License,Law. BAIX FLOW PROT��T.DEVICE
LJ I am exempt under Sec. B h P C for this maven
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y NOUTSI DE_
w
Oner Data RECEIPT X
WORKMAN COMPENSATION DECLARATION FTA'IURFS PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a ceml0ana
te of consent to self-Irre,m a RECEIPT X
Certificate'e WOrken"Compereationlnsurance ora o'nuffed copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y_ N_
Mail,Bab Q RECEIPT X
Policy p S
1any
EA.SYSTEM-OVER 4(EA)
Cam any _ BUILDING DIVISION FEES
citified copy 6 hereby furnished. GREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
Crnified copy 6 filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.ZX)FT. Date RCCeI t#
(Thlssectlon need nm be completed If the permit 6 for one hundred dollars
($100)or pest.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I codify that in the performance of thework for which this permit 6 issued,
1 shill not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING PAID
WorkvrPComprrn.tlon Lawsof C.hfmmia. Date
O Z Applicant NEW RESIDENTIAL
PLMB. SQ.FT. Date Recei t#
Z O NOTICETO APPLICANM ILaRer making this Certificate of Exemption,you
should become subject to the Workers Compensation provisions of the Labor TOTAL:
fACode,you most forthwith comply with such provfslons or this permit shall be BUILDING FEE
W > dermed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I hereby affirm that there 6 a construction Lending agency for the perfom ELECTRIC FEE
M Z arm of the work for which this permit is issued(Sec.3097,Civ.U TOTAL:
U O Lender.N. PLUMBING FEE
LL t= Lenders Addre.s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdlfythatlhavereadth6appbatlonandrtatethattheabove Inform tion
u correct l agreeto comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r N relating to building construction,and hereby authorize representatives of this
Hcity to enter u Pon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (W4,agree to save,Indemnify an d keep harm les the City of Cu pert loo Date Receipt#
V against hab Buss,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT CTO I0,000 CFM) SUBTOTAL:
against afdlC.tyA coroaquemSe of the
granting of thispermit
`� AIRHANDLINGUNrrroVERto,"CM) CONSTRUCTION TAX
Signature of Appliant/Contractor a EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppnant or future building occu pant store or handle hazardous HEATING UNIT(TO ID0,000 BTU) Date Recel t#
materials defined by the Cupertino Municipal Code,Chapter 9.12,and the e^'�
I Tealth and Safety Code Section 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL 4 `
❑Ys MN.
Will the applicant orfnum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emil hava rdous air coma minsnts as defined by the Bay Area Air
Qua lily Management District? 80ILER.COMP DtI'DR IW.IXU BTU)
Y No
have read the hav materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BBV)
the California Health k Safety Code,Sections 25505,2SS33and 2:534. 1
understa lid that if the build Ing does not currently have.tenant,lhS It 6 my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requtrements which must be met /yam
prior to Issuance of a Certificate of Occupancy. .a. `
Owner or authorlmd agent Date ISSl1EDBY:
TOTAL:
OFFICE COPY
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