23054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
zis' S oti od.Q sT GUS 23054
w s aces: cane:
3' CITY OF CUPERTINO-BUILDING DIVISION
contra o c am:• LIa.N°: APPLICATION I PERMIT fTS"?07 BLUDING-ELECnUCAL-PLUMBINGMECHANICAL CATEGORY CONTROLN
A"Ited/Engineer. Lic.Na,
)/ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: P v PEFMTISSUANCR �^� �/'
LICENSED CONTRACTOR'S DECLARATION �J
I hereby affirm that l am Rcensed under provisions of Chapter 9(commen APPLIANCESRESIDENTTAL JOB DESCRIPTIONingwilh Sedlon 7000)°(Dlvlston3ofthe OuslneeeandProleulonsCode,and my
limns Ir In full fops and c.a , PANELS
Limns Cless Lk. �7s �a
Dale Contractor
ARCHITECPS DECLARATION x11.1000 AMP"'
ail Z I understand my plaed shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Limned professional SIG NS ELECTRICAL
OWNER-BUILDER DECLARATION ]ALCEiCUIT/MLSC
7p, a I herebyalOrmthal l amexempt fromthe Conluctorb License Law for the
following reason.(Section 70313,Business and Professions Code:Any city or
O 'q TEMP.METFROR POLE INST.
�� county which rcrpdreaa permit reconstruct,alter,Improve,demolish,orrepair
anystructure priorto its lsuame,olsorequirestheappllmnt forsuch permit to
Ofile a signed statement that he Is licensed pursuant to the provisions of the ppWFR DEVICES
RContractor's License law(Chapter 9(commencing with Section 7000)of Dlvl-
SWIMMING POOL ELECTRICeIon3 oflhegudemetand Pro(mionsCode)orthat he is exempltherafromand VALUATION
the basis for the alleged exemption. Any violation of Sectlon 70313 by any h /
applluntforaper tsub)edstheapphcanttoadvilpemltyofnam mthan v OUTLETSSN77CHES-F (TURES
Ove I,as o nerdolof the
he pr. NEW RESIDENTIAL ELECTR FT.
�n ❑I,asownerlldotproperty,or oryemployees with wagesr theresole SQ. STORIES TYPE CONSTRUCTION
compensation.Business
work and esdonstructure b not Intended or censeofferL w
or
vis(Sec 7044,to show and PMesslam Code:The Contrador'simprove, hereon law
who ddon oes
apply loan owner ofproperty,
iso n ilds empayees,povidedreatsuch OCC.GROUP RES UNITS
MM whodoements am nothimself dedmatio hleownemp,hcov,e,th.b.ildiger
improvement issold NtendneyearfBred pletio.lf,ha neer-builderwdingm TOT l
Improvement b wld within omycaro(cwnplet Wes,the owner-bu0derwW have
ttlLJturdenofpro,ingthethedid not build or improve for purpose ofule.). IT. PLUMBING PERMIT FEE FLOOD ZONE APN
use L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7094,Business and Professbru Code: Ie
The Cont motors License Law does net apply to an owner of property who ALM-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contacts for such pkojects with a
09DUador(s)Boensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lj I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,ARRA•CONTI. SANITARY Y_ N� �.
. ES
Owner Date RECEBrC N
WORKMAN COMPENSATION DECLARATION PER TRAP �s SCHOOL TAX Y N_
.®I hereby affirm that I have o lmu ate of consent to pythure,ora RECEET M
cediflLeb o(Worken'Compe/r�satlonlwpuranm ora nrtlfkd ropythema((Sec. GAS EA.SYSTEM-1 INC40UTLM PARK FEF Y N
Polic38W,y Nb C.) a ' fA
RECEIPT p
CyyynnnRRRaaa ey CAS EA.SYSCEM-0VERd(RA) BUILDING DIVISION FEES
RTCertlfied copy b hembyth the CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
LYJ•-CertlOed copy k(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2DOET. Date Rem! tg
(0)or lm len need not be completed tithe permit b(atom M1undred dollars
($1I cordless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ill Am lythat
ret any paras manynceof mhe anner
se as to become
permltbbo theed, —
I shall not employ any perws In any manner w as to become ubjed las the WATER SYSTEM/TREATING
Workers Compensation laws of California, Date PAID
—
z
Applicant
Z Q PANEW
NOTICETOAPPLICANT:U,ager making this Certificate of Exemption,you NEw RESIDENTIAL Ir1.MB. SQFT. Date Recei
f" should become.ub)octto the Workers'Compensation provblomaf the Labor TOTAL:
f/1 Code,you=at forthwith comply with such provbiom or this permit shall b, U N •EPa
LU j deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
T
Z Thereby af0rmlhat there is a construction knding agency for the perform-
ELECTRIC FEE 4
(�7 once of the work for which this permit is bound(Sec.3097,Civ.C.) PLUMBING FEE
2 Lender's Name
LL I— Lender.Addres. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdlfythatl have read lhbappllcateen and statelhatthe above infomutlon
bconext I agree tocomplywith all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
0. relatingto building construction,and hereby authorities representation of this
YA city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MFCH.
Z (We)agree to save,Indemnify i n d keep harmless the City of Cupertino Date Recei tM
ega1mt11abillties,judgrrppeents,rostsandr enseswhichmaymanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
against.. tylnc bsequereso1 ramie fthl permit.
AIR HANDLING UNIT(OVER 10,000CEM) CONSTRUCTION TAX
SI natvm of Appileart/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIAL DISCLOSURE
Will the applicant or future building occupant store or handle haardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cade Ion? 37G)7 HEATING UNIT(OVER 100,000 BTU) TOTA
[—]Yes o
Willtheappllmnt orfuure bulldingocetrpant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haardous air contomimnts as defined by the Bay Area Air TN T 0
Quality Management District? BORER-COMP OHP OR 100,00108 U-
Y.s ��o
havend. theie&Safes Code,breum 255nb5S33 anhapter.1 of BORER-COMP(OVER IW,IXD BN)
'he
erstand to Health ASafety Code,&ctkm75505,ve a leant,that it 799D
mopareandthat if notify
building does not urrsnllyhavea tenant that itbmy NEW RESIDENTIAL h1ECH. SQ.FT
rnpouibility to nollfy the occupant of them IremeAa which must be 'N
prior toss frtlOcam.1' pa 611 Y �r VVrti"1)
� , •
nor or authorlud agent / to � ISSUED BY:
IOTA
OFFICE COPY