23290 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Address-
Building Project Identification PIJthBT ND.
U4 - 23290
�AU4NE �tse+tofr_ CITY OF CUPERTINO-BUILDING DIVISION
\, Contraao s Gwm4a ,A uAPPLICATION / PERMIT
L1'aZ-
Ow yTN S 4 1+I . BUrLDING-ELECTRICALPLUMBING-MEC MCAL CATEGORY CONTROL N
Architect/Frgoeer. Lk.No:
CITYELE ICP FEE BUILDING PERMIT INFO
Address:
rERnBnssu cE Ibi
LICENSED CONTRACTOR'S DECLARATION LTJ
l Wmbyaffirmthatlamlken.edunderp.W..eof Chapter9(commen N RESIL JOB DESCRIPTION
ingwith Section 7000)0(Divislan3 ofthe Businessand ProfessionsCade,and my
licenseI. nt In furl force and effect.
Ucare
License CUss LION 1 1�'Av v�y'y7►•�
Date Contractor
ARCHITECT'S DECLARATION 201-1000 'S
G I understand my plan.shall W used a public records. OVER1000 AMT'S ) �FT.FLOORAREA $/SQ.F7.
6iLicensed Professional SIGNS RLECTRICAL I[Y�
MH OWNER-BUILDER DECLARATION SI'ECIALCEtCU1T/MLSC
s'${� I herebyaffirmthat l am exempt from the Contnctorb License Law for the
K` qqqq following mason.(SMion 70115,Business and Professions Code:An cityor
counlywhlchrequlresa permlttommtmd,alteanr,lmprove,demolbh,ormalr TEMP.MEPERORPOLE INST. TE
DA ylemcure pd.r to Ib is...ce,.M.qulrestheapplimnt forsuch perMt to
a file a signed statement that he b licensed pursuant to the provblons of the POWER DEVICES
�O Contradors License Law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING POOL ELECTRIC
S:OS sion3ofthe0usinessand Professions Cods)ortbatheis exempithercfromand p��VAL�UATIO6MN
the basis for the alleged exemption. Any violation of Section 70415 by any f��
p<'A4 applicant fora permit subjects the applicant to a civil penalty of not more than OUTLETSSWITCHFSFIXTURES I W✓
e hu five ndred dollars($500).
NEW RESIDENTIAL ELECTR FT.
?a s owner of the property,or my employers with wages a their sok STORIES TYPE CONSTRUCTION
pensation,willdo the work and thestrocture Is net Intended or offered for
O k(see 71114,Businessand Prefesslors Code:The Contracto's License Law
$$ does not apply to an owner of preperty who builds or improve thereon,and OCC.GROUT' RFS.UNITS
who does such work himself arthreugh his own employee,provided that well
Improvements are not Intended proffered for sale.If,however,thebullding or TOTAL:
Improvement harld wlthmoneyearofcompletlor,theowner-builderwill have
l"oden of proving that he did not build or improve for purpose ofealk.). Qly, PLUMBING PERMIT FEE FLOOD pOH ApN
LI I,as owner of the property,am exclusively contracting with licensed PPRMLLLSSUANCE
rontomene to construe the project(Sec.7044,Business and Professions;Cade:
The Contractor'.License Law does net apply to an owner of property who ALTER-DRAIN&VENr-WATER(EA)
Wilds or Improves thereon,and who mouses for such plujem with a
c(tador(s)licensed pursuant to the Contraeora License Law. FEE SUMMARY
LJ I am exempt under Sec. B &P C for'this'reason BACK FLOW PROTECT.DEVICE
CUTS'OF F FS
DRAINS FLOOR ROOF,AWA,COND. SAMTARY Y N
Owner Date RECEIPT-
WORKMAN COMPENSATION DECLARATION FIXNgFq PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have• tmum M of acedtf d pytheure,ora RECEIPT N
ce00,La eofWorken'Compersationlnsurance ora mrtlfkd copy thereof(Sec. GAB-FA.SYSTFM-IINCAOUTLETS pARKFEE Y N
Polis lab C.1
Policy q RECGAS FA.SYSITM-OVER 4(EA) DING DI'N
Com any BUILDING DI VISION F[¢5
Certified copy b hereby wmle CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE 3 I � C
❑Certified copy b Bled with the city
ity inspection division.
CERTIFICATE OF EKEM PTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.200FT Date Recei t#
Qhissedlon need na utWbe completed If the-.sett V(Drone hundred dollars
($100)or1y that WATER HEATER W/VENT/ELEcTR ENERGYFEE Y N
I.not thato they Pa.1 sof the war,so as tobtela subnt is issued, —
I shall not employ any-Lawn In any manner at a to become subject to the WATER SYSTEM/]TREATING
Workere'Compensatlon laws o(011fomla.Date PAID
O Z Applicant Date Recei t#
Z NOTICE TO APPLICANT.If, NEW,after making this Certificate of Exemption,You RESIDENTIAL PLMB. SQXT.
should become subject to the Workers Compensation provisions of the Labor TOTA '
N
CWyou must fodbw th mmply with such proal ions orthb per t shall be DINC "�
`> deemed revoked. BUIL
WCONSTRUCTION LENDING AGENCY - SEISMIC FEE
a C Thereby afflrmthat there he a mrutrectlon lending agency for the perform- FEE
ELECTRIC 7'O ance afthe work for which this permit is Issued(Sm 3097,Civ.C.) TOTAL. EELECTRIC FEE
V lenders Name
LL 1— I.Lnder.Addm.s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have read thlsappfiratlonand tlate that the above inforrrution
V cored.I agree to comply with all city a ad county ordinances and nate laws PERMRISSLIANCE FEES PAID:
} 1 relati ng to building construction,and hereby auteorlm representatives ofthls
j— 00 city to enter upon the above-mentioned property for Inspection purpose. ALTER OR ADDTO MECH.
Z (We)agree to save,indemnify an of keep harmless the City of Cupertino Date Receipt#
V against liabilities,judgments,met.and expenses which may in any way.come AIR HANDLING UNIT CEO 10,000 CrMj
against said City in consequenceofthe rat ntingof tel a parmit SUBTOTAL:
?OAA" rs _ _ A �1 qZ MRHAN1lLING11MTroVERIo,(g0CF'M) - CONSTRUCTION TAX
Slgwmree.fAppllcant/Contrsdor-- V Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
NAIARDOUSe NLS DISCLOSURE.
-
Will the applicant orfuwre building occupant store or handle haurcims I MATING UNIT(TO 100,000 BTU) Date' Recei _
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Iiealth and Safety Cade Section 25532(a)7 I MATING UNIT(OVER 100,000 BTU) TOT
❑Yes MN.
Will the applla of or towns building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
while emit hara mines air mn/amlvnt.a.defined by the Bay Area Air
.lily Management District? BOILER-COMP OFR'OR 100,0(0 BTU) PAID
Ya ❑❑No
have read the bzallous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) FE
the Califomla Health&Safety Code,Sections 25505,25533 and 25534.]'
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.PT.
responsibility to nal Ify the occupant of the requirements which must be met ^'rY
prior to issuance of a Certificate of Occupa nry. 1a 1 uF.
92
�fa��� Cry/!IY V
Owner or authorized agent Data ISSUED BYJ
TOTAL:
OFFICE COPY