23471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMUTNO.
"goo 23471
phone: r A CITY OFCUPERTINO-BUILDING DIVISION w
• Comm "
� LIc.Noe APPLICATION I PERMIT -_3L
BUILDINGELECTRICA[PLUMBING-MECFIAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRM1TIS5UTANCE 1:1C�f� E]LICENSED CONTRACTOR'S DECLARATION
Ihereby
ectionaffirm that 0)of Di Bcen3oftheunder provisions
andP ffe a=sr9(commmc APPUANCESRESIDENTAL JOB DESC ON
I cze.I Section(a.and affeon3o(the Bualnessand ProfesslonsCode,and r^Y
licenac Is In!uB forge and affect. PANELS
Llcanse Clan Lich
Date Contractor LIP TO 2111Sir
ARCHITECT'S DECLARATION 701-1000AMPS
MOb
lonZ I understand my plans shall he used as pubic records. OVER 1000 AMPS SQ.FT.FLOG EA ,p`1 $/SQ.FT.
Llcamcd PnefexsIl SIGNS ELECTRICAL L E ® B , tl
OWNER-BUILDER DECLARATION p� p (I 1
a SPECALCIItCNT/MLSC 18� OVII u
f., Thereby affirm that]am exemptfrom the Contractors Lkense Law for the
p.. following rcuon.(Section 7Q11.5,Business and ProfealOns Code:Any ctty or / ��
OZt county which mquiresa permettocansWct,alter Improve,dm
eolish,orrepaar TFMP.MEITR OR POLE AST.
g
anystmu mpriortoitsb ame,abomqurcstheapplicantforsuchpermltto POWER DEVICES DATE
`5 O Elle e signed statement that lu b licensed pursuant it the pronasions of the ` _j
Contractor'sLiceweLaw(Cfrealm (mnurentlngwltexemptherefomara- SWIMMING POOL ELECTRIC VALUATION
pp O slo basis for
the alleged
d Professions Any violation f Seem therefrom and
the basis(or the alleged exemption. Any violation of$Miont]mt5 by any OUTLETSSWITCHESFIXTURES
OO applicantRnot m
fora permit subjesthe applicant to a civil penalty a not than
Ive mireddo1hn(5.500). NEW RESIDENTIAL EUECTR SQFI. STORIES TYPE CONSTRUCTION
�f I,as owner of the property,or"y employees with wages as their sole
7. nation,wBldothe work,and thestructure is not intended or offered for,
'O sale(Sec.7044,Business and Protesvionv Code:The Contractors License Taw
S$ does not apply to in owner of property,who builds or Improves thereon,and OCC.CROUP RFS.UNITS
E who doessuchworkhter elforthrough hbownemployess,pmrvidedthat such
Improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement lasold withmonerarofcompletiorytheowner-bu0derwlil have
t rden of proving that he did net build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
mU1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code: �
TM Contractor's License Taw does not apply to an owner d property who ALTER-DRAW&VFM-WATER(EA)ALTER-
Wild. or Improves thereon, and who contra for such pPFcts with • FEE SUMMARY
r7L4+ctor(s)licensedrsnse
puuant to the Contractors LiceLaw. BACK FLOW PROTECT.DEVICE
LJ I a exempt under Sec. ' B&P C far this mavenOUTSIDE
DRAINS.HAOIC ROOF,AREA,CON I. SANITARY Y_ N_
Owner " Date - RECEBTa
t O Gs1 CO 1P SATION DECLARATION FIX'IVRFS PER TRAP SCHOOL TAX Y_ N
F11hereby affirm that I have•certlRate of consent to self-insure,ora RECED'C Y
3800,Lab
C.)00,Laof Worken'Compensationlnsurance oracamafied copy therw((Sec. GAS EA.SYSTEM-11NCd OUTLETS PARK FEE Y N
38RECEIPT M
Policy N GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
❑Certlfled copy is hereby furnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy ex filed with the city Inspection division.
CERTIFICATE OF O(EM VFION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE - SHIVER SANITARY STORM EA 200FT DRIB Recei t#
(This section need not be completed If the permit b for ane hundred dollars
(sla)orim.) WATER HEATER W/VENT/kT.ECTR ENERGY FEE Y_ N_
I amity that In the performance of the wok for which this permit is kssued,
I shall not employ any person In any manner so as to became subject to the 1 WATER SYSTEM/TREATING „w' PAID
Workee Compensation taws of California.Date
OZ Applicant NIEW RESIDENTIAL PLMB. SQFT. Date Reeei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions ofthe Labor TOTAL:
ccN ns Code,you most comply with such provisions;orthis permit shall be BUILDING 'E
W > deemed revoked.
CONSTRUCTION LENDING AGENCY v SEISMIC FEE
M Z eof th workfrwhichthis affirm that there is construction lending agency f.C.) perform, p d0 ELECTRIC FEE
7 anceaf the work for which this penton Is issued(Sec.31197,C1v.C.) TOTAL:
02 Leader's inane PLUMBING FEE - n55
ly F Leader's Add mss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1me.Iagree to e read comply with
allcationanddc rutsthat theabovedgateas"
C I imingt building complywlthantltyand county ordinanas and stat Slaws IPE4MTT ISSUANCE FEES PAID:
miming ldingpont construction,ove-emboned hereby Property
or Inspection
n represnpurpo of this
I.. Tz cit(Wa)aree to sae,indenrdlyan d propemyfor Ape N City
Cu es.For ALTER OR ADD TO MECH. Date Rtte1Pf#
(We)agree to save,andenWtts and keep harmless the City of Cupertino
V a a at lhblluan,' d ts,wets and expenses which ms In an cense AIR FANOLING IWTf(DO 10,(100 CFM) SUBTOTAL:
8 N B"'S" a Y Ywaya
ag
id City sun ince oft granting of this permit.
3 36 _q AIR tinNDUNC UNIT rovtR looaocEM) CONSTRUCFION TAX
Igrsturcof Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturc building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
nuterial as defined by the Cupertino Municipal Code,Chapter 9.17,and the
IlealthandSafety Code Section 25532(a)7 HEATING UNIT(OVER IW,"BTU) TOTAL: •Q
❑ Yes E]Ni
WRliheappllantwfuturebaldingocwpantusecxpsipment ordevices VENTILATIONFAN(SINGLERESID) ISSUANCE DATE
which emit harardomaftwntamimusasde0ned bytMBay Area Air A I
Quality Management Diarictl BOILER-COMPOHBPOR1D0,000BTU)
Yes MN.
ihave madtheharaUousmateriabrequirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BN) MAR 30 1992
the California Health&SafetyCode,Stolons 25505,25533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESI DENTIAL MEGs. SQ.FT
resmnt
Feasibility to notify the mcupaest of the mqu irees which most be met n1VV
prior to&suancS ofa Certificate of Occupancy. Cilli Ur UUr LIGI4
Owner or authorised agent DateTOTAL: ISSUED BY; t yAy
— -
OFFICE COPY