22034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Posted ldensllioUon PF7I.MIT NO.
Building
.O3 a� ei 22034
soneIN
sore: one: A
•� CITY OF CUPERTINO-BUILDING DIVISIONI y�f^�{)
. ContraRor'eNa�}} LIc.No: APPLICATION I PERMIT u "� 1
GKT�C !y D SO Y Z BUILDINC-ELECTRICAL-MUMBINGMECHAMCAL CATEGORY CONTROL M
Architect/Engineer. Lt.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 05`/L-�/i!�✓ •` �4 ter/ ��G I{�I PERMITISSUANCE ❑ ❑ ❑
LICENSEDCONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provlMonsa(Chapter 9(mmmenc- APPLIANCESRESIDENTAL JOB DESCRE'TION
Ingnse is Ictlon 7000)of DlWect. (the Bualnessand l§o(nslonaCode,and my - 1a+arysa`
Ilan.lsln full roues and e.# PANELS ` ,
DanacCh® Lor P`
Date ConhactorIM TO 200ANIPS
ARCHITECTS DECLARATION 201-1000Al
Q CZO I understand my Flout shall be used u public records. OVER IODO AMP5 SQ.FT.FLOOR AREA S/SQ.FT.
Fi (/ Licensed I'mfesslmul r SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECGLCIRCNT/MISC
amsess
I herebyafl mthat Is.exempt from the Contractor's License Law for the
0 .-p following reason.(Section 7011 S,Business and Professions Code:Any city or
O Z,1TEMP.METER ORPOLE INST.
E,� anystm mpriorr"poredaismancpermit vmmrequitruct. ltheapmvntfor, cher tto
any structure pdement that
he gaicense pursuant to
fonuions of cit a OWER DEVICES COO
�o. (Ilea signed statement that M Le licensed pursuant ft the tio.7001) I the
3w� Con3 ofthe License and
orthat withxempttherefof Divi- SWUThBNG IDOL ELECTRIC VALUATION
elon3ofthe Business and Pro(essbnsCode)orthat hebexempt themlromand �
0 5 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLCTSSWITCFIFSFIXTURES 31
applicant fora permit subiectsthe applicant to a civil penalty a not mom than
live hundred dollars($500).
I,as owner of the property, NEW RESIDENTIAL ELECTRSQFT. STORIES TYPECONSTRUCTION
�n p ork ya or my employees with wages r there sok
cele&.Don, haborill do thework andthe,Code:
eh not Intendedorsensed!or
5 O do LCsc 7061,Business and Professr ty Code:The Contractor's Lerner law
whodoe apply toanownerofthroug property who empoyes,provided
that much
OCC.GROUP RFS UNITS
CC.• wprove such are neworkht
msededoraugh hlsewne.If,ho es,prthebildingh
ImprovementsarenMIntended armee pleloe.I(h er-g deer ldingve TOTAL:
Improvement 6sold wlthlnoneyearo(complMiorytheowner-bullderwlll have
ilfurden of proving that he did not build or Improve for purpose ofsals). QTY. PLUMBING PERMIT AODZONE APN
LJ 4 PEE Was owner of the property,am exclusively contracting with licensed
mPERMIT ISSUANCE
nmet.to coretruct the project(Sec.7046,Business and Professions Code:
The Contractor's License law does net apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
Wilds or Improves thereon, and who contracts (or such plojects with a
coS(pcuma)licensed Pursuant to the Contnnofs Lt..Law. BAER FLOW PROTECT. FEE SUMMARY
L�I am exempt under Sec B k P C for this reason
Owner Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
. WORKMAN COMPENSATION DECLARATION BBC=N
I hereby affirm that I have a arti0ute of consent'to self-lesurs,or a FIXTURES PER TRAP SCHOOL TAX Y N
c Iflcate of Worken'CompensMlanlnsurance ora certi(led copy thereo!(Sec. RECEB'TM
3800,Lab C.) GAS FA.SYSTEM-1 INCAOUILETS FARRIER Y N
I'oliryM GAS G.SYSTEM-0VER6(EA) RF-C UrfM
Com ray BUILDING DIVISION FEES
Certified copy is herebyth the city
GREASE/INDUSIRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy V(lied with the tlty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-MRM EA.200Pr. Date Rec'el tN
ffhsection need not tr complMed lithe permit V forona hundred dollars
(S100)morlessJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I in
person In
anymofthe work fora to acopermitoIs Owed,
1 shall not employ any person In any manner n ns to become wbje t to the WATTR SYSTEM/TREATING
Workers'Compensatlon lawsof Callfomh. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQFf. Dale Recei t#
Z NOTICE TO APPLICANT:If,after making t his Certificate of Exemption,you
Hshould become subject to the Wtolmes Compensation provbimu of the labor TOTAL:
f/2
Code,you=at forthwith comply with such provigorm or this permit shall be BUILDING
W > deemed revoked.
0. 3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafflrm that there h a commotion Lending agency for the per(orm� ELECTRIC FEE
2 ance of the work for which this permit is awed(See.3097,CIv.C.) TOTAL:
U O IcndelsNane PLUMBING FEE
LLh' lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I ceditythat I havemad this appBalionand statethatthe above Information
1 Ismrrect.I agree to comply with all city and many ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relating to building constmMion,end hereby authorize representatives o(thls
.F. 2 city to enter upon the abovo-mentioned property for Inspection purposes. ALTiRORADDIOMECH. Date Recei tlf 1
(We)agree to cave,indemnify an d kap harmiess the City of Cupertino
against liabilities,judgments,cost sa^d expenses which may In any wayacerue At R HANDLING UNIT(TO 10,000 GEM) SUBTOTAL:
agabutsaid City in consequenceofthe ntlagofthhpermit.
�,C.(.0,6,c.Q,,,p {�IrS/yl AIR HANDONG UNIT(OVER IO,W0CFM) CONSTRUCTION TAX
Slgwmre^(Appliant/ r to IXHAU51 HOOD(W/DUCT) CONSTRUCTION TAX PAID:
RUO MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reaeiplll
I ealth and Safety Code Section 25532(.)7 HEATING UNIT(OVER 100,000 OTU) TOTAL:
❑YeaNo
Willtheapplicant or N.],.Ilding.pant..e quipmentordeviccs VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air mntaminsnts as defined by the Bay Area Air
Quality Ma rugemcat Dist do? BOILER-COMP DEEP OR 100,000 BTU)
❑n Yes 9❑No
Ihave read the hazardom materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Ilealth k Safery Code,Sections 25505,25533 and 25534. I '71 GG J Q
understand that if the building does not aurently have a tenant,that It is my NEW RmESIDENTIAL MECFL SQXT. AI-f�Q G s� ��p'�
responsibility to notify the occupant of the requlroments which most be et
prior to issuance ofa Certificate afO=p.ncy.
Owner m autharlad agent Date ISSUED BY:
TOTAL:
OFFICE COPY