20029APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMITNO.
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pP� m/}QJ / C/¢� I'loane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION it PERMIT
BUILDING-ELECTRICAGMUMBING-MECHANICAL
A
Contracom'e Name: (' Lie. N.
fes! / /V �^ O LEL£ C 4-1432
CATECARY
CONTROL N
Arc iced/Engineer. Lic. No:
QrY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
PERMITISSUANCE
❑ A7l ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
[hereectionrtn that ).Ma .icensedheBur rovLandPfChap Code, and
in ease I Section 7000)0(4 effeon3otthe Buslnessand ProfessloaCode, and my
licenselsl,i fulljjorcu a}�d c.# !
CV L:- ��(y LIC # /?y %
API7.IANCESAESIDENEIAL
JOB DESCRIPDON
JOB
PANELS
Date Contractor C' Ukis
ARCHITECTS DECUBATION
]understand my pias shall be used mpublic records.
V _t G2111
10
OVER IW00AMPS
SQ. FT. FLOOR AREA
S/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SpECiALCIRCUIT/MI.SC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lawlor the
TEdp.METERORPOLEINSf.
following reason.(Section 7031.5, Business and Profevbna Code: Any city or
cmntywhich mquimsa permit tommtme, alteq Bnpmve, deenlbh,or repair
anystrudure proem its issuance, also requlrestheappilunl for such permit to
Ole a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
Contractor's License Law (Chapter9(mmmencleg with Section 7000) of Divi-
slon3 of the Businessand Professions Code) urthat he b exempttherefromand
VALUATION
the basis for the alleged exemption. Any vlotatkm of Sedion 7WIS by any
applicant for a permit subjects the applicant to a civil penalty of not room than
1TILETSSWITCHESH%IURES O
five hundred dollars ($500).
I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQ'FE.
STORIES
TYPE CONSTRUCTION
a20 00
ompression, will do the work and the structure Is not intended or offered for
sale (Sec. 7006, Business and professions Code: The Contractols Wmae Law
does not apply to an owner of property who builds or improves thereoo, and
who docseuchwork himullorthrough hisownemployms, provided that such
.GRO
RFS. UNITS
TOTAL: 9
Improvements are not intended orotfered for sale. If, however, the building or
Improvement is sold within oayearofcomptetion, the owner -builder will have
t rd en of proving that he did not build or improve for purpose ofasle.).
"I, as owner of the property, am exclusively contracting with licensed
matradme to construct the project(Sec. 7040, Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD PDNE
APN
PERMIT ISSUANCE
The Contndo's License law does not apply to an owner of property who
bu Rdn or improves the.eon, and who contracts for such Projects with a
cojdlactor(s) licensed pursuant to the Contractor's License Law.
u I am exempt under Sec. B & P C for thin reason
ALTER -DRAIN & VENT- WATER (EN
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR BOOR GOND.
SANITARY Y_ N_
RELEiPE N
J T % Y_ N_
RECEIPT N
P Y N
RECEIPT #
BUILDING DIVISION FEES
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm certificate that I have a of consent to self -Insure, ora
certificate of Worken'Compcmatfon Insurance or a mrtifled copy thereof(Sce.
3800, lois C.)
Policy N O CI Y %O L b 3
FIX.fI1�S PER TRAIa
CAS EA. SYSTEM -1 INCA CMFLETB
CAS EA. SYSTEM -OVER 6 ( —
Go, a �'OrIA U/` �P
f I Certlfled copy is hereby furnished.
rLYS CertiOM copy is filed with the city Inspection division.
CREASE/INDUSTRL WASTE CEPTOR
PL NC}iECK FEE
GREASETRAP
CERTIFICATE OF EXETIPEION FROM WORKERS'
PAID
SEWER -SANITARY -STORM FA.
COMPENSATION INSURANCE
(Thissection need not be completed If the permit IsCoronahundred dollars
Date Receipt#
WATER HEATERW/VENT/ELECTR
ENERGYFEE Y_ N_
($100)orlcss.)
I mrtily that to the performance of the work forwhich this permit is Laved,
SYSTEM/TREATING
I shall not cmptoy any person In any manner soas to become subjectto theWATER
Workers'Compensation Laws of California. Date
PAID
n
NEW RESIDENTIAL PLMB. SQFT.
Applicant
Date Recei t#
NOTICETO APPLICANT: D, after making this Certificate of Exemption, you
should become subject to the Workers Compersation provisions of the Labor
TOTAL:
BUILDING ' EE
Code, you most forthwith comply with such provisions or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
.�
Ihereby aflrrnthat there inamestrudion lendingagency forthe perform-
ante of the work for which this permit In Issued (Sec. 3097, Civ. C.)
lender'. Name
Lender's Address
state that theabove information
I certifythat I have read thLnapplicationaM ma
Cscorrect. I agrestocomplywithallcityand countyordlnancesand statelaws
PLUMBING PEE
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representativss of this
city to enter upon the above-mentioned property for Wp000n purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
Ilabllltles,judgments, sorts dexpnnx ch mayl anywayaccrue
ALTERORADDTOMFLH.
Date Receipt#
AIR HANDLING UNTf 8010,000 CFM)
SUBTOTAL:
ugalat Id City In moseque c ft gra his pe it
AIR HANDLING UNIT (OVER lO,WO CFM)
CONSTRUCTION TAX
u of Applicant/Contractor. Date
IXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT(TO 100,000BTU)
Date ReceI t#
WIIl the applicant orfumm building occupantstore or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Health and Safety Cod ion 25532(e)2
❑ yea No
Will the applicant sore building occupant use equipment ordevices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENITLATION FAN (SINGLE RESID)
IT11W DATE
which emit harardom air contaminants as defined by the Bay Area Air
Olality Management st' 7
alcrialsrequireenteunderChapter6.95of
h vareadthehaza usmm
)) l,!10
2
MAK 6 193
BOILER-CDMP OHPOR 100,000 BTU)Y.
BOILER -COMP BTU)
the California Health & Safety Code, Sections 25505, 75533 and 25530. I
`understand that if the building does not currently have a tenant, that it is my
m
LeMIRIcubility to notify the oc pant of th quircmeots Which most be et
City, of rBR9rtlno
NEW RESIDENTIAL MCC] i. SQ.FT
prim to suanceo/a Ger iii- of Oc ry.
ISSUEDBY: s
or authorized agent Date
TOTAL:
Y
OFFICE COPY