23831 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Profen Identification PEILWTNO.
B"tiding Address:
23831
AJwPYF:am
: ane:F :
Cp o— 00 CITY OFCUPERTINO-BUILDING DIVISION
Caa •a Na LIc.N°: APPLICATION / PERMIT
++ H77 lApp BUILDINGFLECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL
Archuett/Engineer. Lk.No: '
QTY ELECTRIC PERMIT FEE BUILDINGPERMITINFO
Address: 21,51 fo -cZ k G- PERMITISSUANCB ❑ ❑ 11L�
LICENSED CONTRACTOR'S DECLARATI
I hereby affirm that l am licensed under provisions of Chapler9(mmmene- APPLIANCES-RESIDENTIAL DESCRIPTION
Ingwith Sce6.0000)of DivlMoa3 ofthe Buslnessand ProfesslonsCeds,and my
license la in fol o ddfect. IRITIS t
Llcen �ic.tl_to_7� M ��
Date -fL ontrattor / /I,- 11
ARCHITECTS DECLARATION 201-1000 AMPS
Q 2C I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
ZU Licensed Professional SIGNSELECTRICAL 11�' ® Na
OWNER-BUILDER DECLARATION �Y
G F SPEC ALCDRCUIT/M 5C
i.., Iherebyalfirmthatlam nemptfrom the Contractor's LoereeLaw ydtythe , n
og following res on. Stolon 7031 S,Bminess and Pro(essl.na Code:Mycity or �g METER OR POLE INST. eU
qcaunty which requbesa permit tocorstmn,alter,Improve,demolish,oreepair
W any stmcture pdorto its Issuance,also requiresthe applicant forsuch permit to POWER DEVICES
IWbS s file a signed statement that he Is licensed pursuant to the proall°m of the
O c: Contractor.Lieree law(Chapter 9(commencing with Section 9000)of Dml- SWIMMING POOL ELECTRIC �AT
30 Mon 3 o the Business and Prolesslona Code)orthat heis exerepttherefromand VALUATION
15 y.' the bash for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCIiESE%TUIRES
applicant fora permit subjects the applicant to a civil penalty of net moelun
? five hundred dollars($500). NEW RESIDENTIAL ELECTRSQ.FT, STORIES TYPECONSTRIICTION
1,as owner of the property,or my employees with wages as their sale
compensation,wllldothe work and the structure b cart Intended or offered for
' p sale(Sec.7044,Business and Professore Code:The Contractoes License law
({$$ does not apply to an owner of property who Wilds or improves theme,and OCC.GROUP RES.UbTrS
whodoessuchwork himself orthrough hlsownemployen,prewidedthat such
Improvements are not Intended orolfered tarsale.IL howeveq thebuild(ng or TOTAL:
improvement issold within omyearofcompldiogtheowner-bu0derwlll have
th rdenof proving that he did not Wild or improve for purpose of ask.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LL as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to coretruct the project(Sec 7064,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who _
Wilda or,) ce
linse thereon, and who contracts far such wRojecte waALTER-DRAIN&VENT-WATER(EA)
h a FEE SUMMARY
offictor exempt under Sec)the Conerattofs License Law. BACK FLOW PROTECT.DEVICE
IJ 1 am exempt under&c. B&P C for this mason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date DRAINS- 9
WORKMAN COMPENSATION DECLARATION pl%'ILRES PER]RAI' 50-10011,TAX Y_ N_
�1 hereby affirm that I have a certificate o!consent.self-Insure,ora RECRUIT 0
rerUflcateofWarken Codpc.1i.n Wurancem.certified copy thereof(sec. GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N
3800.Lab C.) O ` s /'/.L DING DIVISION
Pdlry tl � '� GAS FA.SYSTEM-OVER 4(PA)
Com any by t5 �VI�' BUILDING DI VISION FEES
�certlled copy is hereby furnished. PLANCHECK FEE
mil Certified copy ia filed with the city Inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR
`Tf CERTIFICATE OF EXEMPT[ON FROM WORKERS' GRF�ETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFr. Date Recei t#
(fhlssectlon need not be completed If the permit a for ane hundred dollars
(510o)or less.) WATER HEATE4W/VENT/ELECTR ENERGY FEE Y_ N_
I certilythat in the performance of the work/orwhich this permit Is Lssued,
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compensalmn Laws of Califomis.Date PAID
O Z Applicant NEIN RESIDENTIAL PLMB. SQ}T. Date Recel t#
Z U NOTICE TO APPLICANT:If,after ma king this Certificate of Exemption,you
should become subject to the Worm
kers'Compensation provisions of the Labor TOTAL:
Code,you must fort hwuh comply with such provisions or this perdu shall be BUILDING "E
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d IherebyafRrmthat thembaconatrunlon lendingagency for the perform TOTAL: ELECTRIC FEE
D Z once of the work for wh,chth malt is bsued(Sec.3097,Civ.C.)
U O lenders Nam MBING FEE
LL H Leadcr's Address QTY. MECHANICAL PERMIT MECHANICAL FEE . 0
U Icertlfythatl have mad thisapplicatlonand Mate that the above Information
O W Is correct l agmato comply with all city and county ordinances and Mate laws PERMIT ISSUANCE .0 FEES PAID-
r (L relatingtobuilding construction,and berebyauthortea representatives ofthis
Z cit t entero upon above-memionM for 1 ALTERORADDIOMECH. Date EYCIPt#
F Y° po property Peet°"of Cups.
(n, Ere
to nae,Indemnity an d keep harmless the City of Cupertino AIR IiANDWNC UNIT RO 10,000
V agalret 1121 el dgments,coMsa expenses which may In any wayaccme SUBTOTAL:
against. in consefutwit. granting ofthleparrnu. CONSTRUCTION TAX
L f AIR HANDLING UNIT(OVER 10,00 C .
Signature.( Pont/ an near —C•- EXHAUST 110013 fW/OUCH CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DISCLOSURE a1
Will the applicant or future building occupant stmeor handle hazardous HEATING UNIT O0100,000BN) V Date RCCCIpt#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety CcIC ion 2SS33(a)t HEATING UNIT(OVER 100,000 BTU) TOTAL:
F-1YesWNo
Will the applicant or future building occupant use equipment ordevices VENDIATIONFAN(SINGLERESID) ISSUANCE DATE
which emit haaardous ab contammants as defined by the Bay Area Air
Quality Management D BOILER-COMP OfI'OR 100,0(13 BTU)
Yes No
Re 4hane read the hazy ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000BN)
the California Health&Safety Code,Sections 75505,25533 and 75534. I /!a
understand that if he building don not currently havaatenan4 that it is my NEW RESIDENTIAL MEGH. SQ.R l� p
responaibilliyt atity the occupant.(the requlrementa which must be met �'Y
- 'prior to ua eof tate ofocevpancy. /el,
API
dagent Date TOTAL: ISSU[iD BY; I
OFFICE COPY