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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO.
/llS P4105 e/2,Or Q2
21444
sere 'ame: one:
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CITY OF CUPERTINO�BUILDINGDIVISION
APPLICATION / PERMIT
contraaor'awme: Lic.No:
x/L
L R OS(aq
BUfLDINGELECTR(CAI MUMBINGMECH LAICAL
CATEGORY
I
CONTROL N
Amhimet/Engineer. - Nd
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
!� /�
Add— LN -rH,sg ✓[... C—+U l�
I'QthHTISSUANCE
❑ 1:1 ❑ L�I
LICENSED CONTRACTOR'S DECLARATION
I herebythaffirmthat land
APPIRANCESRESIDEMIAL
]OB DFSCRII'IION
PANELS
ma stan3oftheunder uMne PmCsions9(rommenc
inoner is action form of DiWelon3ofthe Buslneuand Pro(asionsCodcand my
license b in fail forte and k. #
License Class
\
Date Contractor
Contractor
J
AMPS
ARCHITECTS DECLARATION
I understand my plain shall W used a public records
OVER00
OVER 1000 AMPS �
SQ. Ff. FLOOR AREA
5/SQ, FT.
SIGNS ELEC L
Licensed Professional
SPECIALCIRCUI
OWNER -BUILDER DECLARATION
1 herebyalflrmthat I am exempt from the Contractor's License Law for the
TEMP. EER E IN
following reason. (Semon 7031.5, Business and Professions Code: Any city or
mntywhkhrequb apert ttocomtmct,alter,improve,dernlbh,orrepair
anystructure prior to its bsuance,abo mquirmtheapplicant for sopemduo
file a signed statement that he b licensed pursuant to the pmvislo�u of the
g -
EflhCTRIC
Contractor§License Law (Chapter 9 (commencing with Secilon 7DOO of Divi-%4q3�0(X
slo lofthe Buslnesaand PrefeeslonsCode)orthaf hebeaemptherc/romand
VALUATION
the bash for the alleged exemption. Any violation of Se Hon 7m15 by any
applicant fora permit subjects the applicant to a civil penalty of not room than
OUD. , SLVI FiX.illRpS
five hundred dollars($5DOL
I, as owner of the property, or my employees with wages as their sole
NEW RESI AL ELECIR SQ.FT.
STORIES
TYPE CON5IRUCT'ION
c cop reaBon, will do the work and the structure b rot intended or offered for
sale (Sec. 7064, Business and Pmfeslom Code: The Contractoes License Law
does not apply to an owner of property who Wilds or Improves t hemoR and
who doessuchwork himself orthicugh hlsownemployees, provided that such
OCC.GROUP
RFS UNITS
TOTAL:
improvementsarc not Intended oroffered for sale. I(howeveq the W ilding or
Improvement lesold within oneyearofaompletion, the owner -W Ilderwlll have
tIj�ku rdm of proving that he did not Wild or improve for purpose ofsale.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to mnatruct the project (See. 70K Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who
Wilds or improves thereon, and who contracts for such projects with .
�gLt[actor(s) Bcensed pursuanttothe Contractor'sLieerse Law.
exempt under Sec B k P C for this reasonOUTSIDE
ALTER -DRAIN Na VENT WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
ROOF, AREA, COND.
SANITARY Y N
RECEIPT N
Owner DateDRAINSFLOOR,
WORKMANCOMPENSATIONDECLARATION
❑ I hereby affirm that I have a certlfi ate of consent to self -Inure, or
certificate of Workem'Compersation Insurance or a certified copy themof(Sec.
3800, Lab C.)
FIXTURES. PER TRAP
SCHOOL TAX Y_ N_
RECEIPT N
GAS EA. 5YSTEM-1 INCA OUTLETS
PARK FEE Y N
RECEIPT N
Policy N
Com any
GAS EA. SYSTEM -OVER 6 (EA)
BUILDING DIVISION FEES
FCertified copy b hereby furnished.
RGI Certified ropy b filed with the city inspection division.
GREASE/WDUSTRL WA57E INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
Y' CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SANITARY.STORM EA 2.'OOFT
COMPENSATION INSURANCE
(fhb section coedeta be completed if the permit lsfor ora hundred dollars
(810)oeless.)
I certify that In the performance of thework forwhich this permit is blued,
Date Recei t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N—
WATER SYSTEM/TREATING
I shall not employ any person N any manner so is to become subjectto the
Worken'Compemationlawaol Caimmia. Date
PAID
NEWRESIDENTIALPLMB. SQ.FT.
Applicant
Date Revel t#
NOTICETO APPLICANT: If, after making thisCertificate of Exemption, you
should become subject to the Workers' Compessatlon provbiom of the Labor
TOTAL:
BUILDING FEE
Code, you =at forthwith comply with such provisions or this pemdt shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
I hercbyalirm that there b a construction lending agency for the perform-
ance of the work for which this permit Is Issued Igoe. 3097, Clv. C.)
lander. Name
Lenders Addreaa
I certify that I have read this application and state that the above Information
bcormet. I agree to comply with all city and county ordinances and slate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICALFEE
PERMIT ISSUANCE
FEES PAID:
relating tobullding construction, and hereby authorize representatives of this
city to enterupon the above-mentioned property fee Inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
against babillBes,judgments, mats and expenses which may in anywayaccrue
ALTERORADDTOMECH.
,
Date RCCCIPt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
against said City in consequence of the granting of this permit.
AIR HANDING UMT(OVER 10,000 CFM)
CONSTRUCTION TAX
Signature of Applicant/Contractor Date
EXHAUST HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
'
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllcant or future building ompant store or handle hazardous
HEATING UNIT (TO IDQ000 BTU /y.�
Date Recel t#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
Cade Son 25532(a)7
tlealth and Safety cH
F1 Yes r] No
Will the applicant orfutum building occupant use equipment or devices
HEATING UNIT (OVER 10D,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management Mind?
have read the materials requirements underChaper 6.95 of
4 Ye Q ;°
a
BOILER-COMP(311P OR 100,0(10 BTU)
BOIL BTU)
the Glifomia tI®Ith k Safety Code, Sectio. 25505, 25533 and 75534. I
understand that if the building does not currently have a tenant, that it is my
responsibility to naly theocaupant of the rtquirements which must be met
NOV
NEW RESIDENTIAL MECH. SQ.F-T.
prior to Issuance of a Certificate of Ompamy.
As JV
ISSUED BY:
Owner or authorized agent Date
TOTAL:
OFFICE COPY