23033 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Prean Identification PERMITNO.
Build i gAdd : ;r,� 2 3 0 3 3
(l7Y/) one: APPL1nVff579I797MrXr p
CITY OF CUPERTINO-BUILDING DIVISION
c r Lie.Ne: APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBING-MEC}IAMCAL CATEGORY CONTROL#
lowArchltat/Engl
a Gy//I QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: /I ' S / / / PERMITISSUANCE ❑ of ❑
LICENSED CONTRACTOR'S DECLARATION
JOB
I hth by affirm that Smtin7D00)of Di Bernard ion3ofheBusiprovisions o(Chapter9(emmmc MPLIANCESRESIDENTTAL JOB DESCRIPTION
Ingwlth5en1on7000)0l Dlvifect. (the BuslnevandlhefnslonsCode,and my �s
Iicenxis in f d(ec[. --�(/-� PANELS
License Cb Lln#
Dat Contrad
7EC 20I1000AMPS
qC ARC all be used
DECLARAii Ned u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.Ff.
qw�v O ZO I understand my plans shall be
u�j Licensed PvdessLued SIGNSELECTRICAL
in 74
< OWNER-BUILDER DECLARATION SPECIALCTRCUIT/MLSC -�
Fp„ > 1herebyaffirmthat l am exempt from the Contractor's License Law for the
70-l.i.� following reazon(Section 7031.5,Business and Professions Code:Any city or TEMP.MEI' OR POLE INS(.
F�p county which requlrequiresa permit to construct,alter,improve,demolish.or repair
y g.'ri any structure prior to its issuance,a Lao requires the applicant for such permit to POWER DEVICES
file a signed statement that he b licensed pursuant to the provisions of the
Ore Contractor's Limn,xx mv(CMpter9(mmmmingwlth Setkn7000)of Divi- SWPTMING IY)DL ELECTRIC
SOC' sion3ofthe Buelnasand Profesalons Code)orthat hebexem Ihere(romand VALUATION
a �.'S the basis for the alleged exemption. Any violation of Section 70313 by any OUTLETSSWITCHESFD(TURES
�5applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars(5500). NEW RESIDENTIAL ELECTR FT.
❑I,as owner of the property,or my employees with wages as their sole _SQ.Fr. TYPE CONSTRUCTION
s,Z6 compensation,will do the work and the structure b not Wended or offered for
F� D vie(Sec.7054,Business and Professions Code:The Contratoes License Law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUT' RFS.UNITS
whodoessechwork himseQorthmugh hisownemployers,provided that such
Improvements are not intended oroffemil(in sale.If,however,thebuilding or TOTAL: ,
improvement Issoldwithln oneyearofcompletian,the owner-W ilderwlllMve
mgJ;urdenof provingthat he did nm Wild or improve forpurposeo(sale.). QTY. PLUMBING PERMIT FEE
LI of m FLOOD ZONE AI'N
[as owner o property,am exclusively contracting with licensed PERMIT ISSUANCE
ne Contractor's
to coruWn the project(Sec.apply
Business and Pf prop rtCode:
TTe Coor improves
License Law aces mat apply tct an owner of properly who ALTER-DRAW&VENT-WATER(EA)
Wilda or improves tpursua and who maters for such w.ojeN with a FEE SUMMARY
co actm exempt
under Sec.
the Contractor'+License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B&P C for this reason
OUTSIDEFECS
DRAINSFLOORROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT_ #
K
WORMAN COMPENSATION DECLARATION pD(TURFS-PER TRAP SCHOOL TAX Y_ N_
I have.ce
I hereby affirm that have a nate i0of consent to self-Inevrc,ora RECEIPT M
certificate of Workn%Comperuatlonimuranaora erti(ied copy themof(Sec. GAS FA.SYSTEM-1 WC<OU1LETS PARK FEE Y_ N_
3800,Lab .)
I'oticy# RECEIPT N
GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Camp#
I ILenmed copy is hereby fumish�. -I GREASE/INWSIRL WASTE INTERCEPTOR PLANCHGCK PEE
L�YII Certified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' IGREASETRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-SIC)RM EA 200Ff DBIC RCCCI (#
(This union need nut be completed tithe permit b foram hundred dollars
($1W)or less) WATER HEATER W/VENT/M TR ENERGYFEE Y_ N_
I aerti(ythat in the performanmof the work forwhich this permit is beved,
I shall not employ any person In any manner x as to become subject to the WATER SYSTEM/TREATING
Workera'Compensatlon Laws o(Glifomla.
Data
PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ.FT. Date Remi O
ZU NOTICE TO APPLICANT-.11,after making this Certificate of Exemption,you
I_
N should become subject to the Workeri ns
Compeation provisions ofthe Labor TOTAL:
I ; Code,you at forthwith comply with such provisions or this permit shall b, BUILDING FEE
deemed revoked.
W
O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there k a construction lending agency forthe perform TOTAL: ELECTRIC FEE -�
M Z ance ofthe work for which this permit b inseed(Sec.3097,Civ.CJ
(,) O Lendrra Name PLUMBING FEE
LL ~ Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certifythat l have read that application and stntethatthe above information
O W bordinanceslagree ta comply with all tltyand county ordinances and state lawsPERMIT ISSUANCE FEE$PAID:
>. IL relating to building construction,and hereby authorize representatives ofthb
F U) city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH. Date Receipt#
(We)agree to save,indemnify and keep harmless the City of Cupertino
U
against lubWties,Judgments,mats and expenses which may insole wayaccrue AIRHANDLINGUNITGO10,000CF1,I) SUBTOTAL:
zgait tlCity In ne qua eaf he rtin o thlep rmit.
AIR HANDLING UNIT(OVER I0,00a CFM) CONSTRUCTIONTAX
of Applicant/Contractor t EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATC A SDISC URE
Will the a ppliant or(uture Wilding oempant stereo ehasardous HEATING UNIT(TO 100,000 BTU)
Date Receipt
I#
material as dented by the Cupertino Municipal Code,Chapter 9.12,and the �_
Halthand Safety Code Section23532(a)I HEATING UNIT(OVER IW,000 BTU)
❑ Yes M No
Willtheappllant or futumbuilding occvpantuuequlprrcnt ordevim VENTILATION FAN(SINGLE RESID) SUAN(CEE DATE
which emit hazardous air contaminants as defined by the Bay Area Air PAID
1 y
Quality Management District? BOILEEL OMP DEEP OR 100,000 BTU)
4Yes ❑❑No
have read the hazaments materials requirements u oder Cha pier 6.95 of BOILER-COMP(OVER 100,000 BT U) 'JUN. e.V O ����
the California Health&Sa fety Code,Sections 25505,25533 and 25534.1
ucad crsta nd that if the building does not current ly have a sena nL that it b my NEW RESIDFNTIAL MECH. SQ.FT
responsbility to notify the occupant of requirements which must W mM CII YUr GUhrtn I ll
m "^
prior uses me of a Certificate of Occupancy. F'
Owner or authorized agent Data TOTAL: ISSUEDBY_
OFFICE COPY