24354 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Btiflifirig Project Identili<ation 7 PFJLWTNQ 4 3 5
Building Addrev: Z
e • one: APPUCAIIUNIUUMII IAL
r CITY OF CUPERTINO-BUILDING DIVISION
rcn dnraw Lie. APPLICATION / PERMIT
BUILDING-D.ECnUCAI.PLUMBINGMECI IAMCALCATEGORY CONTR LN
ArchRect/ Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Acidmu: PERhITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
withS on7Othatlamtheresed under si=3ofhcHuMrovaAdPffh.n.C9( .anm APPLIANCESRESIDENfIAL JOB DFSCRII'UON /
ixxosel5cction7000)of Dlvlslon3ortneBuslnessand Pro(essionscode,and & �•/p- F1Q1EPAaF.
license isles fuB dfect. PANELS �7e'.I
Elate as - LIC N_---lJ t r e
Date y Contractor 03 0 Q.t Roo II nV�
ARCHITEOPS DECLAR TI 201-1000 AMPS
p] Iunderstand myplaruahalbeuad espublic mcurds OVERIODOAMPS SQ.FT.FLOOR AREA f/PQ.FT.
OSIGNS ELECTRICAL
r�U Fj Licensed Professional
a Q w OWNER-BUILDER DECLARATION
In Fn SPCCWLCIRCUIT/MLSC
]F�a Iherebyaf@mthat lam exempt fromthe Contractor.License Law for the
following reason.(Section 7031.5,Business and Professions Code:Any dty or
I. TEMP.METER OR POLE INST.
muntywhich requires a permit tooretmct,ilter,improve,dennlbh,orrepalr
anystwdumpdortoi0W ance,aborequimtheappUmntforsuchpem tto POWEt DEVICES
File a signed statement that he V licensed pursuant to the provislom of the
Contractors License Law(Chapter 9(commencin with Section 7000)of Divi- SWIMMING 100E ELECTRIC
on3ofthe Businessand ProfessioneCodc)orthathe V exempt therefro
siand
`url<5 the basis for the alleged exemption. Any violation of Section mVALUATION
7031.5 by any OUTLEISSWITCI E FIXTURES /7 �s
�j applicant for a permit subjects the applicant to a civil penalty or net more than `C;Z O• D v
c. live hundred dollars(5500). NEW RESIDENTIAL ELECTR
/ F]I,as owner of the pmpsrty,or my employees with wages as their sok �'�' STORIES TYPECONSTRUCTION
5 compensation,will dothe work and the structure b not Intended or offend for p sale(Sec.7044,Business and Professions Code:The Contractors Limme,Law
({5$ does not apply to an owner of property who builds or improves themes.and OCC.GROUP RES.UNITS
E whodoe w&workhimseBmthrarghhlsownemployees,providedthatwch
Improvements am not Intended oroffered for sale.If,however,theWilding or TOTAL:
improvement lssold withinoneyearorcompletion,the owner-budderwill have
tryAka men of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
I_I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontmdora to construct the project(Sec,7044,Business and Professions Code:
The Contractor.License law does net apply to an owner of property who
Wilds or Improves thereon,and who contracts for such pkojero with a ALTER-DRAIN&VENT-WATER IRA)
cgnt[actor(q licensed pursuant to the Contractor.License Law. FEE SUMMARY
L�I am exempt under Sm. B &P C for this mason BACK FLOW PROTECT.DEVICE
OUTSI DE FEES
DRAINSFTOORROOF,AREA,COND. SANITARY Y N_
• Owner Uate RECEIPT
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCdiOOL TAX Y_ N_
1 hereby affirm that I hive a rertlficate,or consent to self-Inwre,or a RECEIPT If
certificate ofWorkers'Comperestion Insurance ora mAifid copy themof(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,Lab C3
Policy# � ' 9 STT J-- CAS F.A.SYSTEM.OVER 4(EA) RECEIPT#
Com an / �� BUILDING DIVISION FEES
enCNd copy ti hereby famished. CREASE/INDUSIRL WAKE INTERCEPTOR PLANCHGCK FEE
IRed copy V tiled with the cityWpedion division. p
CERTIFICATE OF EXEM PTION FROM WORK ER S' I !! PAID
COMPENSATION INSURANCE EWER-SANI'TAR 1. RM _ Date Receipt#
(rhissection need not M completed tf the permit b forone hundred dollars
($)00)or lay.) jjpw • W/v .Lg ENERGY FEE Y_ N_
` imrtify that M the pedormanceoftne work for which this permit is Weed.
I shall not employ any person in any manner m as to becorre wbjvct to the
Workers Compensation laws of California. Date W /TREATI PAID
O Applicant Date Recei t#
Z NEW RESIDPNIIAL PLMB. SOFT.
Z O NpTlCETO APPLICANT:If,aftermakingpir Certificateis Exemption,you
ahold become subject to the Warkese'Gompvasatbn provisions o(the Labor TOTAL:
cW Cdpym=stfmthwlthmmply MthsuNpmW iomorthBpermitshallW BUI N E
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
C o (hereby affirm that them is,a construction lendlegagency forthe perform TOTAL: ELECTRIC FEE.
Z ance ofthe work forwhichthis b Lss
permit ud(Sm.3097,Civ.CJ
U O Lender.Name PLUMBING FEE
f lender§Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
0 I mrtifythatl have mad thisappllcationand state thatthe above Information
0 W Iscorrcd.l agreete,complywith all city and county ordinances and state laws PERMUISSUANCE FEES PAID:
} d relating to building construction,and herebyauthortmiepresentativeso!this -
F Z city to enter upon the above-mentioned property for inspection Purposes. ALTIRORADDTOMECH.
(We)agree to save,Indemnify an If keep harmless;the City of Cupertino Date Receipt#
V agai Inks,led tame d, ses whihrrvylnanywayaamae AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL:
agabousal i i sequence theemgofthl it AIRHANDLLNGUNTT(OVER 10,000CFM) CONSTRUCTION TAX
gnatvrcof Appli AZA rector �Pfe� IXHAllS'f HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HA2& OUSM IALS UISCLOSURE`/
Will the defined
by
future build goavpantrtom h Ater 9.hmmous HEATING UMT(TO 100,000 BTU) Date Recei t#
materialasdefinedbythe di.n2no MunicipalCde,Chapter 9.17,and the -
IleanhandSafctyCedrScction75537(a)7 HEATING UNIT(OVER IW,OW BTU) TOTAL.
❑ Yes n No
Will theapplicant re future building occupant use equipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit herardous air contamimntsascieRmd by the Bay Area Air l,
(a
• Quality Management District? B0ILER-COMPpHPOR100,(X(IBTU)
Yes No
have I I
read the b. ou materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) NOV as
the Celifrnla ealth&Safety Code,Sections 25505,25533 and 2534. 1 1111 S 6 1992
understandtluUfthebuildingdoe Mn rmntlyhaveatenanLthatltlamy NEWRISIDENTIALMECII. 5Q.FT.
resporuibllity to notify the occupant of the requimmnnts which must be met CITVI I UI-
priortoissuanceofaCertificateofOnvpanry. LU, r
Owner or authorised agent Date TOTAL: ISSUED BY:
OFFICE COPY