23291 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Buidinsg`Address:
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9 n et U ftR CITY OF CUPERTINOL BUILDING DIVISION
�Conaadora Name: ,�- Llo No: APPLICATION / PERMIT ` (r
BULDING-ELECTRICALPLUMBING-MFLHAMCAL CATEGORY CONTROL If
rchltect/Gglnee Lie,No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERh9TISSUANCE ICI 1:1 11 ❑
LICENSED CONTRACTOR'S DECLARATION LTJ
Ibereby affirm that l am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTIAL �Q JonR�q�"�1��)I�� y ��
IngwllhSedion7000)ofDtWsion3oftheBusinemaddProfessionsC ,and my rCF7oV�. V'��#vl71nIV
license Is in full force and effect. PANELS " V
License Class LLCM
Date Conerador
ARCHITECTS DECLARATION 201-1000 AMPS
a0 2 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FC.FLOOR AREA f/SQ.FT.
O
Licensed Professional ISICNS ELECTRICAL
6 OWNER-BUILDER DECLARATION
IJn SPECWLCIRCUT/M1SC
Ibereby affirmthatlem exempt from the Contractor's License Law for the
p0 following reason.6ection 70315,Buslnessand Profeaslons Code:Anydty or TEMP,METER OR POLEINST.
F Q examtywhich requtresa percent tomrutruct,alter,improve,demolish,orrepair
q'ryy�pJ any structure prior to its issuance,abomquirestheappliant(ureuch permit to POWER DEVICES
EKE. file a signed statement that he C licensed pursuant to the provisions of the
3u, Contractor's License Law(Chapter 9(commencing with Section 70W)of Divi- SWIMMING NMOL ELECTRIC VALUATION
O A n3ollhe Businemand Profmlom Code)orthatheCexempt lherelromand
5
the basis for the alleged exemption. Any violation of Saloon 70715 by any OUTLET&SWITCHFSSFIXTURES
pQ
applicantPutsapermit subjects the applicant too civil penalty of not more than "w
e. F live hundred dollen he pr. NEW RESIDENTIAL ELECTR FP.
�� ❑I,as owner of the property,or my employee with wages as their sole _SQ.FP. [S TYPE CONSTRUCTION
�7Q mmpematlon,willdo the work,and thestmeture C not intended or offeredfor
9�O sale(Sec.7004,Business and professions Code:The Contractors License Law
N$$ does not apply to an owner of property who builds or improves thereonand OCC.GROl1P RFS.AMTS
who donsuchwork hineseRorthrough hisownemployeen,provided that such
Improvements are out intended oroffercciforsale.If,however,thebullding or R n ^ I_SOTAL:
Improvement lssold withinomyearofcompldiogtheowner-buiiderwill have _ y.,
tlin,Igvden of proving that he did notbulld or Improve for purpose ofubJ. QTy. PLPE
UMBING RMIT'u '� 0 Isy,E FLOOD LONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE1 s
cont radonto construct the projed(Sec 7044,Business and Professions;Code:
The Contractor's License Law does oat apply to an owner of property who ALTER-DRAIN&VENT-fV
Wilds or improves thereon,and who contracts for such p(oj"with a
cgngadoKs)licensed pursuant to the Contractor's License Law. BACK pLv9i'R9.1. ICE FEE SUMMARY
Lf I am exempt under Sec. B&P C for this reasonOUTSI OF PITS
RAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner Date RECEPT#
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y— N—
❑1 hereby affirm that I have a certi0vate of consent to self-Imre,or RFGmrT#
oxoiflate of Workeri Compensation lruursnce ora certified copy theueof(Sec. GAS EA.5Y5rFM-11NC4 OUTLETS PARK FEE Y N
3800,lab Q
RECEPr#
Policy
mcy# GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISI ON FE ES
Cy
nertified copy C hereby fumished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20OFT Date Rewi t#
(Thissectlon need not be completed lithe permit Is for one hundred dollars
(SIM)orlm0 WATER HEATER W/VENT/ELECTR ENERGYFEE Y— N_
I certifythal in the performance of the work forwhlch this permit is Caved,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTAL PLMS. SQ.FT. Date Recei t#
Z O NOTICETO APPLICANT.If,oftar makingthisCertificate of Exemption,you
should become subjed tothe Workers'Compeeutlon provisions ofthe Labor TOTAU
¢ w Code,you must forthwith comply with such provClocoorthis permit shall be BUILDING FEE
deemed revoked.
W > CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL e I hereby alfiunthat there Is a construction lending agency for the perform- ELECTRIC FEE.
M Z ane,of the work for which this permit is Issued(Sec.3D97,Civ,G TOTAL:
U O Lenders Name PLUMBING FEE
IL I— Lenderapddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW IcertBythatI havereadthisappllationand sate that lheabove Information
a bcorrect.Iagreelocomplywithalldtyand rountyordlnancesand state laws PERMIT ISSUANCE FEES PAID:
>. mlatingm Wilding comtruction,and herebyauthorlu representatives ofthI3
F V) city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of CupeNna Date Receipt#
V against liabilities,judgments,mrts and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a imtaai r r in conseluena of the granting of this permit. AICONSTRUCTION TAX
ll R HANDLING Uh7T(OVER lO,OW CFM)
O�-1� �� —
Signature li nt/Contndor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU TOTAL. �
F1 Y. 1]No
Will the applicant orfumm Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which rout heanrdousair contaminants as defined by the Bay Area Air
. Quality Management Mind? BOILER-COMP(3FN OR1W,IXgBTU PAID
4YesNo
havc read the h.Q us materials requirements underChapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the CulBomia Helth&Safety Code,Sections ESD5,25533 and 75534.1 SEB = 7 1992
u ndersta od that if the bu llding doe not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.Ff
respoe ibility to notify the occupant of the requirements which must W and
prior to Issuance of a Certificate of Occupancy. CITYUF a�s CUNtn ung
Owner or authorized agent Date ISSUED BY- ah�
TOTAL:
OFFICE COPY