23904 APPLICANT TO FILL nIINaINFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLYBuilding Project tion PE nnTNo.
Building Address:
-Lo2 3 9 0 4
w
wners ante: - 4No:
A A
V P Y OF CUPERTIN66UILDING DIVISION
Contr LiAPPLICATION /PERMIT
r UILDING-ELFQTRICALPLUMBINR-MEC CAL CATEGORY Ir T
Amhitect/Enginee LiL C/
ELECTRIC PER FEE BUILDING PERMIT INFO
Address: RMITISSUANCELICENS EDCONTRi under SDECLARATION I hereby affirmthat lam lkeneed under provLslone ofChaon PPLIANCESRESID j0 OA[
tegwith Set1on7000)of Divislon3ofthe Businessand ProfessionsCodgand my
license is in fail force and effect P kNELS ,tea
[.scents Class Lic.p
Date Contractor 1 0 PS O V W
ARCHITECTS DECLARATION pMpg SQ FT FLOOR AREA $/SQ FT
9 CO I unden iced my plans aha°be used.public records.
(� Licensed Prof.kmal GNS LECTRMkl,
QOWNER-BUILDER DECLARATION SPEC IA C LSC
i„ Ihereby affirm that l am exempt from the Contractor's License law for the
Z O- following reason.(Section 7031.5,Business and Professions Code:Any city or q'EMP. OR PO NST.
�Llpppppp'� county which requires a permit to cosatrue alter,Improve,demoltsh,or repair
nystmctumpHortoit6ance,alsomquimstheapphrntfmsu(hpernitto POWEJ DEVIC
W U file a signed statement that he E licensed pursuant to the provlslorts of Me
� u•fn Contractor's License Law(Chapter 9(commencing with Section MID)of Divi- SWIMMIN POOL ELECTRIC VALUATION
O .sion3 ofthe Businessand Profexiom Code)mrthatheisexem therefromand
the basis for the alleged exemption. Any violation of Section 7MIS by any. ETSSWTTCHESFIXTURFS
µ+u06 applicant for a permit subjects the applicant to a civil penalty of not more than Z O ID 400
two hundred dollars(5500). NEW RESIDENTIAL ELECTR SQ.FT. / nI�Sf T�y(P��yEE\CCf�YY 5 TION
G ❑1,as owner of the property,or my employees with wages as their sole — �J " �^ O tl tl
compensation,will do the work,and the structure b not intended or offered for J /" LI'
❑
sale&c.7044,Business and Professions Code:The Contractors License Law
does not apply to an owner of property who Wilds or improves thereon,and
who does such work himself orthrough his own employees,provided that such O`C CROCJPI III it M. S
improvements are not Intended oroffered forsale.If,however,thebuildingor
improvement issoldwithinoneyearofcompltiogthe owner-WBderwW have /
t"rden of proving that he did not build or Improve for purpose ofsale.). QTY. PLUMBING PERMIT FEED
1_11 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner nt property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such pt,o)Ms with a
co,IlSfactors)licensed pursuant to the Contractor's Llrense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LI I am exempt under See. B&P C for this reasonOUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,
SANITARY Y_ N_
Owner Date RFLEIFT N
. WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
affirm
❑I hereby that I have a cecm
Ncite of consent ser(-inwre,or RFLaPT N
cenificateofWork nCompem timinsurancemacenifLL copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.) RECEIPT N
Policyffany S E.A.
GASYS1EM-OVER4(EA) BUILDINGDIV ONFEES
cont Cnrtlfled copy is hereby fumished. GREASE/INDUSD2L WASTE INTFRCEPTO PLANCHE
❑Certified copy b flled with the city Inspection division. 4
CERTIFICATE OF O(BMPTION FROM WORKERS' GREASE TRAP ISA
COMPENSATION INSURANCE SEWER-SAMTARV-STORM EA.200Ff. Date Recci t#
(Thlssenion need net be completed lithe permit efor one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECTR ERGYFEE Y_ N_
I certify that in the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to became subject to the WATERSYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
OZ Applicant NEW RES DENT ALPLMB. SQPT.
P Date Recei t#
Z O NOTICE TO APPLICANT.It,after making this Certificate of Exemption,you
should become subject to the Workers Compensation provisions of the Labor TOTAL:.
U) Code,you must forthwith compiywlth such provisions orthls permit shall be BUILDING FEE
Wj deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl O I hereby affirmthat there Is a construction binding agency forthe perform- ELECTRIC FEE
M Z ance of the work for which this permit is Issued(Sec.3097,CIv.C.) TOT L: /'
U0
Lenders Name PLUMBING FEE /'�
H Lenders Addreas QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
OW I mAifythatl have readthie applicationand statethatthe above Information �-
1 h;cornect.I agree to comply with all city and county ordinancesand state laws PERMITLSSUANCE w FEES PAID:
} relating to building comtruction,and hereby authorize representatives of this
H
1:0
city to enter upon the above-reentioned property for Inspection purposes. ALTERORADDIOMECH.
_ (We)agree to save,Indemnity and keep harmless the City of Cu accrue Date Receipt#
AIRHANDLING UNIT(TOID,000CFM)
against said
in me nb,costs and expenses which may In any way accrue SUBTOTAL:
against Bald City In conuquenre of the gr ming of this perms
�s �ox �; 91 MR HANDLING UNIT(OVER 10000CFM) CONSTRUCTION TAX
Slgmture of Applicant/Contractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rec i t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 10B000 BTU)
❑ Yns , MN.
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which rout hazardous air contaminants as defined by the Bay Area Air a'Y d
Quality Management District? BOILER-COMP(3HI'OR 100,000 BTU) p
4 Yes F�No VEP,
have read the haza materiab requirements undcrChapier 6.95 of BOILER-COMP(OVER100,000 BTU) �L ��
the California Health&Safety Code,Sections25505,21533 and 25534.I U 92
understand that lithe Wilding does not currently have a tenant,that it b my NEW RESIDEN7TAL MECH. SQ.TT City ser
responsibility to notify the occupant of the requirements which most be me, VV
prior to issuance of a Certificam ofOccupancy.
TOTAL: /t `SCh/q4,V
Owner or authoriagent Date 15SUEDBY:y(`�, .
OFFICE COPY