24141APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Pto'ed Identification
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGEI.ECTRICAI.PLUMBING-MFCHAMCAL
Con
actor's Name: ' Lk. No:
CAIEGORY
CONTROL. M
A ted/Engineer: Lk. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add...
PFRMITISSUANCE
�SYI 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby alfbmthemeunder p yfChapter9(comment,
IngwithSedbn 7000)ofDtWsion3.fth.B.enss.ndProfmimsCode,and my
license le In full f and effect.
License ls LICK
Dale GR
MPWANCFSRESDENITAL
B OF
a
PANELS
UP TO 2D0AMPq
201.1 DOD AMPS
ARCHITECTS DECLARATION
I understand my pisco shall he used upublic records.
OVER 1000 AMPS.
PO. E.FLOOR AREA 5/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCItCIRT/MLSC
OWNER -BUILDER DECLARATION
1 hereby afDrmthat I am exempt from the Contractor's License Law for the
TEMP MET1t OR POLE INET.
fallowing mosm.(Section 7031,5, Business and Profession, Code: Any city or
countywhichrequlmapermitwwmtud,alter,bnpmve,dem itsh,orrepair
any structure prior to it, issuance, also requires, the applicant fee such permit to
Ne a signed statement that be b licensed pursuant to the provisions of the
Contractors License Law (Chapter9(commencing with Section 700)) of Divi-
ston3 of the Business and ProfessioruCode) ortbat he besempt therefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars ($500).
❑ I, as ..or of the property, or my employees with wages as, their sok
POWER DEVICES
SWIMMING BOOL ELECTRIC
OUTLETSSW17CI1PSFIX1TlRE5
VALUA]� y(�i
I b O
NEW RESIDENTIAL ELECTR _SQ.FT.
STORES
TYPE CONSTRUCTION
compensation, will do the work and the sbueture to not Intended or offend for
sale Ike. 7004, Buskure. and Professions Code: The Contractors Lt.. Law
dove not apply to an owner of property who Wilds or Improve, thereon, and
whodoessuchworkhimself orthrough hi,ownemployees, provided that such
OCC. GROUP
RFS UNITS
Improvements are not Intended oroffered formle. If, however, thebuilding or
Improvement bsokl within one yearof completion,the owner-bullderwlll have
TOTAL:
ttlt.1i1rdenofpmving that he did not build or Improve for purpose ofw4eJ.
L_j L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professlou Code:
QTY, PLUMBING PERMIT FEE
PFRMITLSSUANCE
FLOOD ZONE
APN
The Contractor's License law doss not apply to an owner of property who
Wn,
builds or Improves thereoand who contracts for such pnojem with •FEE
ou ctor(e) licensed pu rnuant to the Contractors License Law.
LII am exempt under Sec. B k P C for this mason
ALTER -DRAIN A VENT - WATER (EA)
SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS. ROOK ROOF, AREA, COND.
FD(NREs PER TRAP
SANITARY Y N
RECEIPT 0
Owner Date
WORKMAN COMPENSATION DECLARATION
❑L hereby affirm that I have s certificate of consent to mif-Inure, or •
certl(Icate o(Worken'Compensatlonluursnce ora certified mpy [hennf(Sec.
3800, Lab CJ
Cam i�taa.
SCJ IDOL TAX Y N
RECEIPT M
GAS EA. SYSIFM-1 INC4 OUTLETS
PARK FEE Y N
RECEIVE N
GAS EA.
BUILDING DIVISION FEES
71 Certified copy ls filed with the city inspection division,
71 Certified copyls berdbyth the city
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
CREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200IT.
COMPENSATION INSURANCE
IThis sed na be completed ifthe permit bfaronehundred dollars
Date Recei the
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
It..)
($1I mrtifeu.)
Icertlly that In the performance ofthe work forwhkhthio pgmlt Is towed,
I shall not employ any person In any manner w as to become subject to the
Workers' Compensation laws of CaOomia. Date
WATIR SYSIEM/TREATING
Applicant
NOTICE TO APPLICANT: making this Certificate of Exemption, you
should become subject to the Workers'Compeuatlon proisiou of the Labor
Dafe Rerei I#
NEW RESIDENTIAL PLMB. SQFr.
TOTAL:
Code, you moat forthwith comply with such provisions or this permit shall be
deemed revoked.
BUILDING
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I herebyallimthat there b a construction landing agency forthe perform
ance of the work for which this permit to bued ((See. 3097, Cly. C.)
TOTAL:
ELECTRIC FEE
PLUMBING FEE
Lander. Name
Lender'. Add..
I cadlfythat] have read this application and statethat Iheabove Information
is counted. l agree to complywith all city and county ordinance, and state laws
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
MECHANICAL FEE
FEES PAID:
relating to bullding construction, and hereby suthortu representatives of this
city to enter upon the abovo-mentbmd property for Inspection purposes.
(W a Ince to ssve, indemnify an d keep harmless the City of Cupertino
ALTERORADDTOMFCH.
Date Recei fN
P
agar 11 little', pdgmentn,den.andexpe es hi hmayinanymyoccrue
agai t id City In come nm the ng of this per�plt
CV
AIRHANDUNG UNIT C170 10,MCIM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
St rc ppR nt ont dor to
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Willt applicant orfuure building occupant at.. or hand to b.,dou.
material as, defined by the Cupertino Municipal Code, Chapter 9.IZ and the
Health and Safety Code Sedion 25532(,)7
F1Yes No
Date Receftic
HEATING UNIT (OVER 100,000 RTU)
TOT
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
p
4s, p
Will the applicant or tune Wilding occupant use equipment or devices
which rout haeardous air contaminants as, donned by the Bay Area Air
Quality Management District?
4 Yes d No
haiforead under 6.95 of
car outmode,
BOILER -COMP DHP OR 100,IXD BTU)
BOILER-COMP(OVQt 100,00(1 BTU)
earthhe
the California Health kSa(ety Code, Sections 7:505, 25573 and 25534.1
Schon 25505, 5533 and
W e
NEW RESIDENTIAL MECH. SQ.E
understand that lithe Wlidingdcea not urmnllyh veatcnanl, that itbmy
respo Ibllity to natty occupantthe of the rcqui me which sr' 6s, met
/0
pr r exuanccofa Certtfica of an
P �z
{?J .l 9
V 1g�
ISSUED
or or short ageit
TOTAL:
OFFICE COPY