20180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building project Identification o PERMIT NO.
Bnuaing Add 20180
wners ams: one: APPLICATIONSUBMITr==1_\t1
Cj CITYOFCUPERTINO�BUILDINGDIVISION r L�� Q
Contract ' Name: �\ — APPLICATION /PERMIT
BUILDING-ELECTWCAL-PLUMBING-MECHAMCAL CATEGORY CONTROL N
A
re met Engi ser. Lk.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO'
Address: PERMITLS5UANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyafftrm that l am licensed under provisions o(Chapter9(mmumenc APPLIANCFSRESIDENITAL JOB DESCRIPTION
Ingwith Sechon7000)af Dlvlslon3ofthe Busimmand Pmfesaloms Code,and my n
license U In fug force and effect. PANELS ...�.yy.yy�as4sa��1�N
License CU. LION B' l • I
Dale Contractor Nps���..JJJJ 1 ` '
ARCHITECT'S DECLARATION 201-IODO AMPS
Oz I understand my poreshall be used u public records OVER 10DD AMPS h A SQ.FT.FLOOR AREA S/SQ.FT.
O
Licensed professional SIGNS ELECTWGA
al OWNER-BUILDER DECLARATION SI>ECIAL CHiCU1T/M
'7. Lh.dbyafBrm that l and exempt from the Contractor's License Law for the
following reason.(Section 71111.5,Business and Profession.Code:Any dly or
O t:, TEMP.M• OR ST.
I;�p countywhkh mqulreea permit to construct,alter,improve,demolbh,or mpalr
swcnuretatertolbtwancq licensed
pursuant
t the pro ouch uf.N.ho POWERD
ftLSilS y F floe a sign's aicenseLaw that ha Is(Chapter 9(c ee pursuant encing it the tion 10om of the
3w Contractor's ugmes and Preselom culel orthmhe with Section he,0)o(Divl- VAL{](syQN
SOS don3o(theBueNesaand oenlouCode)orthathebeempthere(romand SWIM LELECTI Oy
0 the basis for the alleged exemption. Any violation of Section 7MI.S by any OUTLE TCHES nn
applicant fora permit subjects the applicant to a civil penalty of not more than
$ five hundred dollars($500).
NEW RESIDENTIAL ELEC ,FT.
7< ❑I,as owner of the property,or my employees with wages a,their wk STORIES TYPE CONSTRUCTION
compensatlon,wW to the work,and lhestmcwre V not Intended cur m((ered(or
O sale(Sec.7044,Business and Pro(esiors Code:The Contractors License Law
pj es$ does not apply to an owners(property who builds orlmproves thereon,and RFS.IJNI'I5
OCC.GROUI'
CG: whodom suchworkbim Lforthmughhisownemploym,providedthatsuch
Improvements are not Intended oraffered for sale.IT however thebullding or TOTAL:
�. Improvement issold withinonerarofcompl&iomthe owner-buBderwglhave
Ken of proving that he did not bund or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
I as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE saey5
o r dors to construct the pm)e,t(Sec.7064,Business and Professions Code: Cl!!ff//
Contesdoes License law don net apply to an owner of property who
Wilds or improve,thereon,and who contracts for such Te jests with a ALTER-DRAW 4 VENT-WATER(EA)
on ador(s)Ilcensedpursuanttothe Conct
traor's Llreme Law. FEE SUMMARY
LJ I am exempt under Sao 'B k C�hh reason BACK PLOW PROTECT.DEVICE OUTSIDE FE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
OwAal Date RECEIPT N
Ow WO IAN COM Flit ION DECLA 1 FIXTURES.PER SCHOOL TAX Y_ N_
1 Fere af( that I have a certifiate of consent to self-Insure,or a RFLEIIPf N
certlRate of 'Corepevatlonlmurana ora certified mpythemof(Sec.
3800,Lab CJ CAS EA.SYSTEM-1 INCA OUTLETS PARK PEE Y N_
Policy N CAS EA. 4(EA) RECEIPT N
Com any BUILDING DIVISION FEES
�Codifled copy U bed with the
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Codified copy is filed bwlth the city Inspection division.
CERTIFICATE OF E)(EMPION FROM WOR KERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.200Ff. Date Ri t#
(Thio sactlan need not M completed lithe permit V(Drone hundred dollars eceP
($Iw)orl..) WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I certify that In the performance ofthe work forwhich this permit is issued, —
1 shall not employ any person In any eamner an es to become subtsd to the WATER SYSTEM/TREATING
Wurkers'Compensation Laws of Califoreia. Date PAID
O Z Applicant NEWRP9DENIIALPLMB._SQ.F7. Date RLYYI t#
Z O NOTICE TO APPLICANT.If,aper making this Certificate of Exemption,you
Fshould become subject to the Workers''Compereatlon provisions of the Labor TOTAL:
a. W Code,you must forthwith comply Mthsuch provisions mthla permit,lull be
j deemed revoked. BUILDING L
W 02
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL F3 Iherebya(Brn that there Is a construction lending agency for the perform- TOTAL: �y ELECTRIC FEE
7 Z ance of the workfor which this permit is lasued(Sec.3097,Civ.U) 1
V O L.endere Name - PLUMBING FEE
LLr Lenaer.Aadreas QTY. MECHANICAL PERMIT FEE- MECHANICALPEE
OW Icedifythatihavereadtheappllationandwawthattheabovelnformation
IL Is correct.I agree to complywith all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. N motlegtobulldingroutrudlon,and hereby authorize representativeso(this
N Z city to enter upon the abovo-mentioned property for impaction purposes. ALTERORADDTOMFAH. Date Retei t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabllitlea,judgments,rostsamd expenses which may inanywayaccme AIR HANDLING UNIT(TO 10,000 CPM) SUBTOTAL:
-9-1-t said City In consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CRM) CONST RUCTION TAX
Signature of Appliant/Contractor Date EXHAUST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous PLEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the _ Date Recei t# qq
Health and Safety Code Section 25532W)? I[EATING UNIT(OVER 100,010 BTU) TOTAL: V
Yes No �_[J�p��i�
Willtheappliant orfuture building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) Iss'�-T-H!!N DATE
which emit haaardous air contamlwnts as defined by the Bay Area Air
Quality Management District? BOILER-COMP OH[POR 100,000 BTU)
4Yea n No n -a
havereacithebrza�ousm�terialsrequirementsunderChapter6.95of ROMER.COMP(OVER100,000BTU)
the California Health k Safely Code,Sections 25505,25533 and 25534.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
rnporsibility to notify the occupant of the requirements which must be met Pity, of Cunettino
ri isuanm ofa Cast( o(Orrepamry. p -.
Owns or au orlud agent Date ISSIII:D BYM/a/Y 1
TOTAL:
OFFICE COPY