19675 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE SALL POINT PEN ONLY
Building Project Identification PIRMITNO.
Building Address:
Phone 1 9675_
Q
a
iter. . CITY OF CUPERTINO4BUILDING DIVISION
G lranorsName: M Lm.No: APPLICATION / PERMIT d L
'•aCATEGORY CONTROLM
( Architect/Engineer. Lle No: BUILDING-ELECTRICAI.PLUMBINGMECHAMCAL
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hemisyaffman that l am Bcensed under provisions of Chapter9(comment. APPLIANCES-RESIDENTIAL - JOB DESCRITIDN
Ingwlth Sectlon7IXp)of DiAslon3ofthe BuMi and PmfesslonsCode,andm
lire..Is In fit ( rce d effect. PANELS
LIcen.Cla. LIc.N Z S ��
Dal .Contractor p
ARCHITECTS DECLARATION 201-1000AMP5
I understand rrry plana shallbe used as public records. OVER 1000 AMPS ( SQ.FT.FLOOR AREA /SQ.Fr.
Ett Licensed Professional SIGNS ELECTRISAZS
05
<Q, OWNER-BUILDER DECLARATION
to a
t. I hereby afRrm that I am exempt fromthe Contractor's License Lw for the SPECIAL CIRCUIT/
7 pp following reason.(Section 7811.5,Business and Professions Code:Any city or
O Z F TEMP.METIR NST.
K, CAY F)
4 countywhkh rcquircse permit lomnstrun,alter, demolish,or repair ,
4 anystmmmpriortoltslmance,alsorequlmlheappllantforsuchperMtto POWER DEW
P O file a signed statement that he V Ilce.sed pursuant to the provbios of the
Q6 O� Contractors License Law RClupterl fica—ndngwlth Section Met).(Divi- kwiMMING ELEC7WC
Lh aten3olthe Beelneeand Pm(esslos Code)orthat helse.mpttherefromand VALUATION
Q the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fare permit subjects the appBcant to a nvll penalty of notmorethan O E'IS H ES
five hundred dollars($500). NE TNT[ L SQTT. STORIES (O TYPECONSIRUCTION
�n
F11,as owner of the property,or my employees with wages as their sole
OPCC compe.sallon,willdothn work and theetsnurels not Intended or offered for
Q .1.(Sec7044,Buai..sandPmfevlos Ccde:The Contractors License Lw
h/i $ does not apply to an owner of property who build,or Improves thtmo,and RFS.UNITSOCC.GROIJIa
EE who does such work himself or through his own employees,provided that such _
improvements are not Intended oroffered forsale.If,however,lhe bulldingor TOTAL:
Improvement lssold wlthlnoneyearofcompletiorylhe owner-builderwlll have
Iti„kurdenof proving that he did not build or Improve for purpose olsale.). QTY, PLUMBING PERMIT FEE
UL as owner of the property,am exclusively mntratting with licensed FT-OOD ACNE APN
contractors to construct the project(Sec.7064,Business and Professlos Code: PERMIT ISSUANCE
Ile Contractor's License Lw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(PA)
Wilds or Improves thereon, and who contracts far such pkajoes with
ott nor(s)h...d pursuant to the Contnnore Lice..Lw. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_,j I am exempt under Sec. B&P C for thin recta..
DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y . N
Owner Date RECEIPT N
WORKMANCOMPFNSATIONDECLARATION FIXNRES PER TRAP SCHOOLTAX Y_ N
❑I hereby affirm that I have a cartiBctte of consent to self-Insure,ora RECER'r N
cerufiate ofWorkera'Compesatlonlsurance or a certified copy thereof(Sec. GAS EA.SYSTEM-11NCAOUTLETS
PARK r•Ee RECEmr If
Go1iryN GAS.EA.SYSTEM-OOVER FA
Com ( ) BUILDING DIVISION FEES
�Certil(edc py is bercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
F-1 Certified copy V(fled with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GRFASE TRAP PAID-
COMPENSATION
INermit for SEWER-SANITARY-STORM EA.200FT. Date Recal tic
s section need not W completed Rp
the permit E(oras hundred dollars
(S100)orless) WATERHEATFRW/VENT/ELFCTR ENERGYFEE Y N
Icertlfy thatlothe penormance of the work forwhkhthis permit bbsued,
I ahall not employ any pawn In any manner so as to berone subject to the WATER SYSTEM/TREATING
Workers Compensation Lim of California. Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB._SQ.Fr. Date Recet tit
O NOTICE TO APPLICANT-.IL making lhla Certificate of Exemption,you
should become subject to the Workers CompesatWn proWlos of the Labor TOTAL:
W Code,you enst forthwith comply with such provbios.rthb permit shall he BUILDING 7-
0.
V
W j deemed revoked,
a c CONSTRUCTION
omtmdlLENDINGen AGENCY SEISMIC FEE O
(hereby afRrm Mut then Raconstmnlonlending agency 7,Civ. ted perform ELECTRIC FEE
L) Z aendersthe work forwhkhthb permit Vi.A,ed(Sec.3097,CIv.C.) TOTAL:
U O lenders Name PLUMBING FEE
LL Q LenaersnahatI Q'rY. '. MECHANICAL PERMIT FEE MECHANICAL FEE
O LU Treed.I agree
havemad mply with allcitll ynand dcounterhattheyordina aboveinformation
IL hcoingt lagmto complytio,andherbyauthyoa,representatives
gatelawsPERMTTISSUANCE FEES PAID,.
} W relating to building costsnlory and hereby authorize repre.ntativcs of thin
H Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECFL Date RecCi t><
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,jedgmenfs,msteand expenses which may lnanymyaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL• ..S
g��ai--TsTt said City In copse ce of a granti of thl.proadt.
�1et 2. y{�s AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
oaturc of ppEe,mt/C traitor Date EXHAus'r HooD(W/DUCT) ' CONSTRUCTION TAX PAID:
HAlAR DOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCYCI I#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Cade SlUNIT2S532(a)7 HEATING UT(OVER 100,000 BTU) TOTAL:
❑Yes �en-
Will the applicant orfuture building occupant use equipment ordevices VENTILATION FAN(SINGLE RERD) ISSIlM1_ DATE
which emit hazardous air rontarrdeants as defined by the Bay Arca Air
Quality Management UlaMn7 BOILER-COMP OFE'OR 100,000 BTU) I
4Yf9 O vJJ
h.ec mdthe haze osmuferiats requiremenfsunderChapterg.95 o! BOILER-COMP(OVQR 100,000 BTU)
the California Health&Safety Code,Sections 25505,25S33 and 25534. I
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr.
responsibility to notify the occupant of the requirements which must be CaItV O} (SII^rtrtlBD
prior to issuance a a Cert fl o c-P ry. t,
nerorauthorimp Date ISSUEU BY: ��
TOTAL:
OFFICE COPY