23126 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERNUTNO.
Building Address: . 23126
03 e3SOP-tlF1e�#�Y '
ners : � % _ one:. A A
(/�a��-v�`p.a*j CITY OF CUPERTINO-BUILDING DIVISION �� 7n CJI
• cnntratnr,Name: �p� Lie.N.: APPLICATION /PERMIT q--q
o NGS b� r c� T RC� BU LDING-ELECTWCALPLUMBING- CA EGORY CONTROL#
Architen/Engineer. Lie.Nce MLCPIAMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
[her byaffSectio 70t)aftheiscensMhe Busiessiand PrfCssions9(rommmc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Inense1Section force and affect ofthe Busiussand ProfessloneCode,and my � �
(cense Is 1.h!uI fora and c.N PANELS
DateLiceuClass LIc.X
Date Cmntrator —IM TO 200AWS
ARCHITECT'S DECLARATION 201-I000AMPS
'J. tardmypla s Ilbetttpu rde. OVER I"AMPS `AFL EI SA 'f/SQ.FT.
E Licensed P'essimW SIGNS ELECTRICAL D
< OWNER-BUILDER DECLARATION SPECIAL CItCU1T/MLSC
L., G Thereby affirm tlutlam exemptfromthe Contractors License hwfor the
7 9-@ following reason.(Section 70315,Business and Professions Code:Any city or
OGI-9 TEMP.METER OR POLE(NSI.
F� � muntywhich rcbes
quapertNt to ronstmct,alter,bnprove, mo
deltah,orrepair
yy Q nystructure prlorto its Lsauance,aLso requires theappllant forsuch permit to POWER DEVICES DAT
file a signed statement that he is licensed pursuant to the pro kions of the
�(OK Contractor',License Law(Chapter 9(mermendng with Section 7000)of Divl-
F�Oa ton 3 otthe Businessand ProfemiomCode)orthat heleexempttherefromand SWIMMING POOL ELECTRICVALUATIO Nom_ _
the basis for the alleged exemption. Any violation of Section 7031.5 by any CJCJ
o OUTLETSSWITCIiESHXTURES
applicant for a permit subjects the applicant to a rnll penalty nt nes more than O O D{
a $ five,hundred dollars(S5DO). NEW RESIDENTIAL ELECTR SQ.FT.
�j C]1,as owner of the property,or my employees with wage,as their sole STORIES TYPECONSTRUCTION
CG< compensation,w0l do the work,and the structure b not intended or offered for
y' D sale(Sec.7D44,Business and Professions Code:The Contractors License Law
�$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
whodmica ch workhimseRorthrough hlsownemployees,provided thatsuch
improvements are not Intended oroftered feesak.If,however,the W Ilding or TOTAL:
improvement issold wlthm one yea rof completion,the owner-W dderwlll have
Oi,kveden of proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with Ilemseci PFRMCf ISSUANCE
contractors to construct the project(Sec.7044,Business and Professlom Code:
The Contractors License Law does not apply to an owner a property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improve,thereon, and who contracts for such pwincls with a FEE SUMMARY
�}Wfator(s)licensed pursuant to the Contractor's License Law.
c LJI am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSI DE FEES
DRAINS FLOOR A,ROOF,AREGOND. SANITARY Y_ N_
O.vner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FIXTURE&PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that 1 have o l rtN of consent to pythmm,or RECEIPT N
'00,ab of Workeri ComperwHonlreurance oracertlf4d copy thereof(Sec. GAS F.A.SYSTEM-11NC4 OUTLETS PARK FEE Y N
Policy N CJ RECEIPT N
Policy GAS F.A.SY91EM-OVER4(FA) BUILDING DI VI SION FE ES
Coom any
ErCerti(Icd copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy x tiled with the city inspection division.
CERTIFICATE OF EX EM PITON FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F1'. Date Recei t#
(Thlssetbn need not be completed If the permit Lafor aro hundred dollars
($100)or I..) WATER HFA.I.FRW/VENT/FI crTR ENERGY FEE Y_ N_
1 certify that N the performance of the work forwhlch this permit Is laded,
I shall not employ any person In any manner so asto become subject to the WATER SYSTEM/TRFATING
Worker(Compm.flo.LawsofC iffomia.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ. . Date Recei t#
Z O NOTICE TO APPLICANT:(,after making this Certificate of Exemption,you
ahold bemme subject to the Workers'Compereatlon provisions of the Labor TOTAL:
0 Cod,you must forthwith comply with such provisions orthis permit shall be BUILDING FEE
W ] deerrd revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Q. I hereby affirenthat there his construction lending agency for the perform ELECTRIC FEE
D Z ...a.ftheworktorwhichthb permit 1,Issued(Sec.3097,CIv.C.) TOTAL:
02 lander.Name PLUMBING FEE
t- Landers Address QTY. MECHANICAL PERMIT FEE
O W Imrtify that l have read thisappBathmurid tatethat theaWve information MECHANICAL FEE
M iscomeat.I agreete,comply with all my and muntyordinanm :
and tate laws PERMIT ISSUANCE FEES PAID
>. relating to building contraction,and hereby authorize representatives of thin
F N city to enter upon the abovo-mentioned property for Inspection pu rposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an If keep harmless the City of Cupertino Date Receipt#
V against liabilities,Judgments,mks and expenses which may In any way acme AIR HANDLING UNIT CTO 10,000 CEM) SUBTOTAL:
against said City in constquence of the granting of this pemnit.
�y�s`�����A/X�^/"� p �, �� � AIR HANDLING UMT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of APpl" icamt/COntractor Date E%I-IAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle havrdous BEATING UNIT(TO 10000 BIIn Date Recei t#
mater ladefinedbythe Cupertino Munttpal Code Chapter9.12,andthe ['-
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTA : v
❑ Yes NN.
Will the applicant orffium building oempant use equipment ordevices VENIL.ATIONFAN(SINGLERESID) ISSUANCE DATE
which emit hatardom air contaminants as defined by the Bay Area Air
Ouallly Management District? BOILER-COMP OHPOR 100,000 BTU) ys{
'?h
Yes FR No Ifs Lt{ N
Ihaveread tcadth&iJfvt mcdc, ectIo lrernentsunder
and 255 . 1 of F10TLER-COMP(OVFR IDJ,DOO BTU)
the
understand
at lith he building
Code not currently
a tenant,25534. I
understand that notify the ocgdoa nese requir haves whichrust itis myma,t NEWRESIDFN77ALMETH. SQ.R. E� 1p
responsibility bBityc notify Ceheoccupantof nmpancquirementswhich must berM b d 190'1
prior to Issuance o(a Certificate otOmpancy. v1
CI I Y Ur n. w
Owner or authoriveda t Date — •f`IV ,✓IL
gen TOTAL: ISSUED BY:
OFFICE COPY