23336 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PMWTNO.
Iiullding d mss- 233-36
ne mc:
AALUAII,
�ne CITY OF CUPERTINO-BUILDING DIVISION 2'Z' 2-
Contnnor'eN LIc.N. APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBINGMECH LAICAL CATEGORY CONTROL N
Ar ten glneer. Lic.No:
Q']Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFAhITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
1:1 E:1 r
❑
I hereby affirm
that am provisions of Ch (commrnc- APPLIANCESRESIDEMNL ]OB DCRI'TION
IngwIthSMom7000).fDw1s.3.fhc BusinausandProfesdonsCde,ond
my
licensecense Is in full!canoe and e.# PANFlS Asil
liClam LIGM
Date Contractor —UP TO 200AWG
ARCHITECTS DECLARATION 2014000 AMPS
N2 Iunderstand my plan shall be used as public remrdw OVER 1000 AMPS ARFAa $/SQ.FT.
qq1+� G L.F� f
Licensed Professioml SIGNS ELECTRICAL
dd G OWNER-BUILDER DECLARATION
aHureempt from the Coneranbs Licenx Law forthe SPECIAL CtCUfT/MISC
�U
T
E R
((( e7vfollowing recnts.(Section 7071.5,Business and Professions Code:Any city or cmntywhichrcquiresapermittommtmd,alterimpmedenlsh,orrepair IpMPMETER OR POLE INST.
anystructum priorlo its issuance,abo requlreslheappBant for such permit to TOWER DEVICES
0 U file a signed statement that he is licensed pursuant to the provisions of the
Contractor's License OLaw(Char 9(commencin with Section 7000)of Divi-
O�n nice3ofthe Business and Profeselons Code)orthat he v exam therefromand SWENMING POOL ELECTRIC VALUATION
Sthe basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWHCHESFIXTURES
666 applicant for a permit subjects the applicant to a civil penalty of not ore than
C, O O five bund red dollars($500).
�r$� NEW RESIDENTIAL ELECTR SQFr. STORIES TYPECONSTRUCTION
j X ❑Las owner of the properly,or my employees whh wags r tMlr wk
,,7� compensation,Business andwill dothe k,and thestronurche is C intended kens ad for
p sale(Sec.apply
Business and Prooperty Code:The Contractor.thereon Law
doas whodot apply loan owner ofproughhisoWilds morlmprw s thereon,videdtatand OCC.GROUP RF5.UNITS
EE wprovemantses such amwork himself omughhisown e.If,ho n,er,thedthatsuch
improvement osold intendedmoney arofc d plebe,the mveveptheerwill g orhave
TOTAL:
Improvement bsold withinoneycarofcompietion,theowner-bWlderwlll have
upnrden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed pptMRI56UANCE
contnnon to construct the prefect(Sec.7044,Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(FA)
Wilds or Improves thereon, and who contracts for such ptojeM with a FEE SUMMARY
cgRtractor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B h P C for this reason
12121511 ELIM5'
Owner Data
DRAINS FLOOR ROOF,AREA,COND. SANTI Y_REC
WORKMAN COMPENSATION
uts DECLARATION PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have a m010cate of consent to self-insure,pth (Sa RECEIPT M
3800,LabC.Work<n'Compenatlonlnurance ora ce0ifled ropythereo((Sm. GAS FA.SYSTEM-1 INCAOUTLEIS PARK FEE Y N
3800.Lab C.)
olq pra
y GAS EA.SYSTEM-OVER 4(EA) RFCET p
oartifiad copy It hereby ficruslusf. BUILDING DIVISION FEESC�C
CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPHON FROM WORKERS' GR .TRAP PAID
COMPENSATION INSURANCE SEWER-SA ARYSIORM EA 200FT �^ Date Recei l#
(I'Nssenlon need not be completed lithe permit bfor on hundred dollars
(5100)orlcn.) W HEATER W/VENC/CLECTR ENERGY FEE Y_ N
I certify that In the performance of the work forwhlch this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Worksm Compensation Lawsof Callfomia.Date PAID
O Z Applicant NEW RESIDENTIAL ELMS. SQFC. Date Recei t#
P
Z O NOUCETO APPLICANT:If,after makinglhitCertlfacate,of Exemption,you
should become,subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions
revoked. -WILDING.n or that permit shall be
W j deem "E
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Z 1hembyaffirmthat there is a mntrunion lendingagenry,forthe perform TOT / ELECTRIC FEE
once of the work for which this permit b blued(Sec.3097,CIv.C3
U O Iender'.N.me PLUMBING FEE ^
F Tonder',Address QTY. MECHANICAL PERMIT FEE
O W I certilythat l have read this appllationand state thatthe above information MECHANICALFEE
4 iscorrect.i agree to comply with all city and county ordinana.and state laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives ofthb
I— Z city to enter upon the abovcmentioncd property for impaction purposes. ALTER OR ADD TO MECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities'judgments,costsand expenses which may In anywayammm AIR HANDLING UNIT(TO 10,(00 CFM) SUBTOTAL:
xgaintral in Caysequenmofihegrantin ofthl. —it.
AIRHANDLING UNIT(OVER l0,000Ch'M) CONSTRUCTION TAX
'ignamm cilApplicgWContractor Data EXHAUSTHOODIW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or town,building m.pant.t.m or handle havrdou. HEATING UNIT(TO 100,000 BTU) Date Recel #
material as defined by the Cupertino Municipal Cade,Chapter9.IZ and the
fiealth and Safety Cade Section 25532(aP HEATING UNIT(OVER 100,W0 BTU) TOTAL
❑Yes M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit lutardous air conn nananis as defined by the Bay Area Air
• Quality Management District? BOILER-COMP PHP OR 10a(300 BTU)
4Y.. ��II No
have read the hazar'7i nns materials requirements under Chapter6.9Sof BOLER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25534. I
understand that if the building don not currently have a tenant,that it 6 my NEWRESIDEN'IIALMECH. SQFT. �� _
responsibility to notify the occupant of the requirements which must berot
tort
prior to Issuance of a Certificate of Occupancy. a��F
f
Owncrorauthorimd agent Data TOTAL: ISSUED BY: '!'±W
OFFICE COPY