19667 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO,
Built„6Addou.: 9667
ner secs: Phone: B -
A
CITY OF CUPERTINQBUILDING DIVISION - �^
Co tractof9Neme: LI[.No: APPLICATION I PERMIT -(f
BLJILDING-MI)CTRICAInP BING-MECIBANICAL CATEGORY CONTROL a
/
mh to Engineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am heensbd under provisions of Chapter9(mmmenc. APPLIANCESRESIDENTIAL JOB DESCRBTION
ingwlth Scvron7000)of DiAslan3ofthe BuMn sand Pmfe ms Code,and my
IlReis InFi.$ effect. PANELS
,me
Llcen I LIc
,to Contractor y 201-1000AMI'S A,
UP TO 200AWq
AR @hall d CLARc re L L�VVV
{qq{++++0O ]understand my plaru eha0 he used as public records. OVERIWOAMPS OR '$/SQ.FL
E Lfce..If Profemlorul SIGNSELECTRICAL
a6 OWNER-BUILDER Ism exempt
DECLARATION U R
rn a SPECIAL CIRGUIT,MIBC E
y F -hereby Affirm,..(SAat l am exempHro ass a d Professions
License Law for the
lo0owing reason.(Section 70315, omtmn and Pimpmlons Code:Any city it
O � TEMP.METER OR POLE-NST.
p4 countywhmph rental p ancoaL requi theapmvgdemoWh,.r tt.
01 �Ts
any a signurepatementehmancq also reed pursuant to the roviM nsof t e POWER DEVICES
file a signed statement that he la licensed pursuant to the provlaloru of the
3µD�+ Contracture License law(Chapter I(commencing with Section 70W)of DIVI- SWIMMING POOL ELECTRIC
F. gun3afthc Buslnesamd Pmfessfarm Code)arthat he i c mmpt therefromand [ VALUATION
Sn the bails for the Alleged exemption. Any violation of Section 70315 by any OUILETSSWITCHESFIXTURES Q
OS applicant for a permit subjects the a ppllcant to a civil penalty of not more than T N ^oe
five undred dollars($500). NEW RESIDENTIAL ELECTR_SQ.Fr, STORIES TYPE CONSTRICTION'
�n �I,as owner of the property,or my employem with wages as their sole
compensatloMwilldo(heworkandthestmu m isnot intended or offered for
sale(Sec.7014,Busineas and Professloro Code:The Contractors License law
r�$ does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RES.UNITS
C• whodoes such work himself or through hlsown employees,provided that such
Improvements are not intended oroftered forsae.If,however,thebuilding or TOTAL:
Improvement lasold withinomyearofcompletb theowner-bullderwlll have
t4L,urdeo of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE67-(X,),ONE APN
”4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to ematruct the project(Sec.7044,Business and Professiom Code:
The ContnRor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA)
builds or Improves thereon, and who contractsd
for such ptojes with a
onor(e)lfrensed pursuant to the Contnciors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under See B& P C for this reason
•
OUTSIDE FEES
Owner ate
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N D
WORKMAN COMPENSATION DECLRECEIPT#ARATION FDMJRES PER TRAP SCHOOLTAX Y N
❑I hereby oolums that 1 have o Insurance
ra c of consent to op thereof ora RECEIPT x
certificate of Worken'Compevatlonlruurence oracertified copylhereo((Sec. GAS-CA SYSIEM—I INC4 OUTLET
PARK FEE Y_ N_
RECEPati N DING'IN
C.
4 �O O.Ar FA.SYSTFJd-0VER4(EA) _ BUILDING DIVISION FEES
Cert�a py herebyth the city
d. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy la Ilkd with the city Irupec[lan division.
CERTIFICATE OF E)(EM"ION FROM WORK ER S' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MET. Date Remi til
(This section need not be completed If the permit la for one hundred dollars
($l ID)orfcay performancea.H
I at In the performanceo(lhewark(orwhlch this penult is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I shall not employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workers Compensation Lowsof Callforela.Date PAID
O Z Applicant NEW RESIDENTIAL PLM( SQJIT. Date Reml tk
Z 0 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Cumpensation provisions ofthe Labor TOTAL:
yCode,you most forthwith comply with such provisions orthis perrat shall be
K > deemed revoked. ••BUILDING 7 00
(LCONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbya(Brm that therelaammwcUon lendingagenry for the pedartry ELECTRIC FEE
D Z mceofthe workfor whlchlhls permit is issued(kc.3097,CIv.C.) TOTAL:
O O Ieru er'a Name PLUMBING FEE
LL F Lenders Addsma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedifythatl have read thlaappliatlonand Gate thattheabove Information
fiscomect.I agreelocamplywlth All citymd muntyovllnancesand date laws PERMITISSUANCE FEES PAID:
} W relating to building mnstruRlon,and hereby authorize representatives ofthis
Z city to enter upon the above-mentioned property for inspection purposes. ALTILRORADDTOMECH. Date Reeei Ip
Me)agree to save,Ind emnlfy an d keep harmless the City of Cu Pontae
sga ust liabilities,judgments,costs a od expensss which may in any way acerm AIR HANDLING UNIT R010,000CFM) SUBTOTAL:
.gal MCI ;,m naequeB .sx
p �(tM`rantin aflhle pennlL
,(/IG /` (t1u V AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
srtumnfA pliant/Coetr or Date E(HAUSTHOODM/DICT) CONSTRUCTION TAX PAID:
HAlARD S MATERIALS DISCLOSURE
Willthe applicant or future building ceupantstore orhandle hazardous HEATING UMT(TO 100,0DO BTU) TRIC RCCeI Ifl
noterislasaetlnedth the Cupc oMunicipal Code,Chapter 9.12,and the
HeahhmdSafetyCad�32(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ,6
❑Yrs , No
Wllltheapplbntor .0 Wilding.pantuseequipmcnto,devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA'Z'E
which emit havardous air contaminants as defined by the Bay Area Air
Quality Management UmLtMay BOILER-COMP QH POR 100,000 BTU)
'1V
I haw read the hares or7us materials mqu tremens under Chapter 6.95 of BOILER-COMP(OVERI DO,(XD BTU)
the CafifomiaHealth&Safety Code,Sectimu255B5,25533and25534.1 f• Q ��„�
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT -La Lj y
responsibility to notify the accvntofth requlremenlswhichrousibemet
ria lssuanre ofa CAAlfl e f my.
1 f In Itiro
ner or authorlmd agent Date
TOTAL: ISSUED BY
OFFICE COPY Gel