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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building _P_m_)'c_n�Identification
Building Address: it(p T.
PFkMITN20456
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CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION /PERMIT
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me
curt act u.. N.:
ILA )A
BUILDINGELECTIUCALI'LUMBING-MECHAMCAL
CATEGORY COMROLjr O.s S"
C7 L•�
Amh"en/Fs neer. LIc Na:
QTY ELECTRIC PERMIT FEE
o
BUILDING PERMIT INFO
Address:
PERbITISSUANCE Z, V
Ill' f�i ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IMrebysffirn that l are heemed under provisions of Chapter9 immense
ingwilh Sectlon 7000).!DMsion3ofthe Businesand Pmfe msCode, and my
license le In full and effect. ifp Q /
Licence Mae
ontr
1Q_Coneranor 4�
APPLIANCESRESIDENTIAL
JOB DESCRIPTION
�v s
PANELS
IMTnWAMMi�r
_
201"1000 AMPS
-Contractor
ARCHITECT'S DECLARATION
I understand my plans shall W used as public records.
OVERIMAMPS
SQ. Fr. FLOOR AREA
$/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
/hercby affirm that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/1,10C
TEMP METER OR POLE INET.
following reason.(Section 7071.5, Business and Profession. Code: Any city or
Countywhich requires a permit to mmtmd, alleq bnpmve, demoli3h,or repair
mystructure prior to its otharemabo mquimsthe applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the
POWER DEVICES
SWIMMING POOL ELECTRIC
OIITLE'ISSWITCFIF.rFl%TURES
Contractor's License Law (Chapter 9 (commencing with Section 7000) of Divi.
sion3 of the Business and Posesk nsCode)orthat he is exempt thercfromand
the basis for the alleged exemption. An violation of Section 70115 an
applicant furs permits whines the applicant to a civil Freaky of not more than
VALUATION
NEW RESIDENTIAL ELECTR SQ.Fr.
fiechundeedeldlars($500).
❑ I, m owner of the property, or my employees with wages as their sole
STORIES
TYPE CONSIl2UCTION
compensation, will d o the work, and the structure Is not intended or offered for
sale (Sec. 7004, Business and Profesiore Code: The Contractees License law
TOTAL:3 -ST
does not apply to an owner of property who builds or improves thereoq and
whodoessuchwork Merselforthrough hlsownemployess, provided that such
Improvements am not Intended oroffemd for sale. If, however, the building or
OCC.GROUP
RES. UNITS
Improvement imold within one year.fcompletlon, the owner-bulW er will have
QTY. PLUMBING PERMIT FEE
lhqurdre of proving that he didem bund or Improve for purpose of sale.).
(J 4 as owner of the property, am exclusively contracting with licensed
to Construct the project (S 7064, Business and Profesns loCode:
FLOOD ZONE
APN
pptMlT ISSUANCE
"
The
The Contractor's License Law does not apply to an owner of property who
Wild. or Improves thereon, and who contracts for such projects with a
"Nadcn(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec B h P C for this reawn
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY
BACK FLOW PROTECJ, DEVICE
OUTS I
FEES
DRAINS FLOOR, AREA, CO
SANITARY Y_ N_
RECEIT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to wIf-insure, ora
cenificateof Worken'Compewtimin mnmmamltitled Copythennf(Sec.
'00. (ab Q
Policy Y
FI%.rIIRE& TRAP
GAS EA. 9Y .40 U
SCHOOL TAX Y_ N
RECEIPT N
PARKFEE Y N
RECEIPT X
GAS-EA'SY VER4
cons any
BUILDING DIVISION FEES
Certified copy Is hereby famished.
Certified copy Is filed with the city Inspection division.
EASE/I Lw -TOR
PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
E WA
PAID
COMPENSATION INSURANCEMyAgy-Sro
(Thissectlon need not be completed if the permit isfor one hundred dollars
Date ReceI t#
33a(o
ENERGYFEE Y_ N_
($l W).rless.)N,
I mdifythat in the performanre.Rhe work for which this permit Is Issued,
F2tl /� R
ATQt /7REAT1
1 shall not employ any person In any manner no s to became srbjee to the
Workers Compensation Laws of California. Date
Applicant
PAID
Date Remi t#
{Jain
NEWR D=ALPI.MB. SQ T.
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers Compensat ton provisions of the Labor
TOTAL:
'1
90 s
_
BUILDING FEEm
Code, you most forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
-
SEISMIC FEE
�s
I herebyaffireettuuhem is a construction lendingagency forthe perform
ante of the work for which this permit is Issued (Sec. 3D97, Civ. CJ
lender's Name
Lenders Addres
I certify that I have read this application and state that the above Information
iscorect. I agree to comply with all city and county ordinances and gate laws
TOTAL:
ELECTRIC FEE
3z.
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authomm representatives of this
city to enter upon the above-mentioned property for inspection pu rpows.
(We) agree to save, indemnify an d keep harmless the City of Cu pertlno
against llabintles,judgments, cors and expenses which may many way accrue
Date Receipt#
ALTERORADDTOMECH.
AIR HANDUNG UNIT DO 10,000 CFM)
SUBTOTAL:
against said City In consequence of the granting of this permit.
6h2Iw
AR ANDUNG INI'r(OVER IO,000CFM)
CONSTRUCTION TAX
—�
u. Applicant/Contractor Dale
Sin
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,0XIBM
Date Rmef t#
eapplicant or future building occupant store or handle hazardous
a defined by the Cupertino Municipal Code, Chapter 9.12, and the
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Ffid yley Cole Section 25532(a)7
❑ Yea No
Will the applicant or uture building occupant use equipment or devices
VENDLATION FAN (SINGLE MID)
ISSUANCGDATE
which emit lurardom ab conlaminsnts as defined by the Bay Area Air
Quality Management Detr7ct7
4Yea jj"�I N
have read the hazardou,o materials rcgalrcmcnla anderGhapter 6.95 of
Y'MCLO,
JUN z 1 I*J
BOILER -COMP (3FIPOR 100,000 BTU)
BOILER-COMP(OVUi lIXI,000BN)
the alfmia Health k Safety Code, Sections 25505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that it is my
NEWRISIDENTIALMECH. SQ.FT.
m nsibili to roti( the occv ant of the ulrcmente which most be met
poor to Issuance of a Certificate of Occupancy.
Glia of runertino
ISSUED BY: —
Owner or authorized agent Date
TOTAL:
OFFICE COPY