24450 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Identification rewwrNq, 4 4 5 0
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Building Adds: _
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nere am, one:
Amy CITY OF CUPERTINO-BUILDING DIVISION
Contrartn'sName: / /I Lie.Na APPLICATION /PERMIT
P, I % • to b1U �/ Y J BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
rchitect/Englmer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihth bdiofbmthatlam Bm3o(heBuWrovlslonsolfha..r9(mmmene- ArrLIANCESRE9DENTIAL ]OBDESC _O^N
ingwith SecHon]000)aid effect. ofthe Buslnceaand Pro(eulons Code,and my i e
limns.Isis full(o and effect. PANCLS
Llmnse Clan- LICM CO L/0 YO 1
Date Contactor :r�..e]r�.6LIP TO 200 AMPS
ARCHITECT'S DECLARATION 201-1000 AMT'S
q�v m0 ZO I understand my phos shallbe used as records.rerda. OVER 1000 AMT'S
SQ.FT.FLOOR AREA S/SQ.FT.
k� Licensed Professional SIGNSELECTRICAL
<<LL OWNER-BUILDER DECLARATION r
rn G SI'ECGLCA2CUIT/MISC E p I N
2E, Iherelatiowrlegby affirreason.m thatI sen exempt from the Contractor's License Law for the
o Opppmuntywhicheclaimsfleeton7m15,BustmetandPmfmive, Code:Any h,or pair
y or
Fzf'� cwntywhich requlmapeemlltomn.huci,alter,Improve, TEMP.METfR ORPOLE]NST.
qy4y anystmdurc priori.ltabwance,aLw requlrestFeappOant(..such permit to YTER
6 C file a sued atatement that he L licensed pursuant to the provisions of the POWER DEVICES
Ok Contractor'.License Law(Chapter 9(commencing with Section 7000 m)of Divi- '/ / ON
�0 sten 3 of the Bushossand Professions Code)orthat he b exempt therefrom and SWIMMING POOL ELECTRIC (/
6 5 the basis for the alleged exemption. Any vlolatlon of Section 7B11S by any OUTLETSSWIiCI IFSI7%TUAES DAT �(_
applicant for a permit subjectstheapplicam to a civil penalty of not ore than
live]],as
neroftheprdollars . NEW RESIDENTIAL ELECTR SQyr. STORIES TYP11CONSTRUCTION
❑I,as owner will
the property,or my employees with wages r thele sole
compensation,Business work andthesiCdurc Isnotintended oroffered..Lfor
e � sale(Sec 7fM4,Business and Professions Code:The Contnctofe Llmnu taw
$ does not apply loan owner of property who builds or improves thereon,and
wheel.es.uchworkhi.lf.rthrcughhls.wnempl.ym.,provldedthat®ch OCC.CROUIa RLS.UNITS
Improvements am out intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement las.ldwithlnomyearofcomplelion,IMe ner-bullderwlll have .,
t1iii.liurden of proving that he did not build or impreve for purpose of sale). Q7y, ' PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed pp1T L55UANCE
contractors toot
o mrelruct the project(Sec.9074,Business and Professions Code:
The Contncior'e Limnse law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such pipjects with a
m actor(s)licensed pursuant to the Commences License Law. BACK FLOW PROTECT,DEVICE FEE SUMMARY
.. u I am exempt under Sec B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date - RFOED'f If
WORKMAN COMPENSATION DECLARATION
❑I hereby affithat I have a mdiflam of convent to self-insure,or FIXTURES-PER RESTER TRM Sgi00L'TA% Y
rm N
certificate of Workers'Compersatio Insurance ora certBled mpythemof(Sec. RECEB'TM
3800,Lab C.) GAS EA.SYSTEM-I INCA OUTLErS PARKFEE Y_ N_
Policy Y d. GAS EA.SYSTEhf-0VCR 4(EA) RECEIIR'M
Com any B U I LOING DI VI SION FEES
[P Certified copy b herebytum
Certified ropy to filed with the e city
ty inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
CERTIFICATE OF EXEMPTION FROM WORK ER S' GREASE TRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIORMEA.20OFr. Date RCCCI t#
(This section need not be completed If the permit V foroM hundred dollars
(Sl(p)orfy that
WATER HG /VONT/E.ECTR ENERGY FEE Y N
[certify that Nthe penfomunaof the work for which this permit is Issued,
I shall not employ any person in any nsnner n as to bemme subject lathe N, 5YMIM/ EATING
Workers'Compensatlon laws of California.Date I PAID
O Z Applicant �p�g. gQ,pp. Date Remi t#
Z Q NOTICE TO APPLICANT;If,after nuking this Certificate of Exemption,you
should bemrte subject to the Workers'Compensation provisions of the Labor TOTAL:
41 Code,you must forthwith comply with such provisions or this permit shall be BUILDING
W 9 deemed revoked. FEE
M C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirmthattherebs.nutnunlonlendingagencyfortheperform D - �, ELECTRIC FEE
V7 = anm ofthe work!orwhich this permit b lamaed(&e 3097,CIv.C.) PLUMBING FEE i
O [..does Name
LL F Lendee.Addem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certlfythatl have readthisapplicattem.ed statethatthe above information
a 6correct.I agree to comply with all city and county ordinances and state laws PERMUISSUANCE FEES PAID:
} relating to building mrstmetles,and hereby authorize representatives of this
U) city to enter upon the above-mentioned property for Inspection pu rposes. ALTER OR ADD TO MUCH.
(We)agree to ave,Indemnify an it keep harmless the City of Cupertino Date Recei t#
V against liabilities,pdgmentqmete and expenses which may In any way arose AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
agairstulti Ci inmnmquenmo(thegranting.fthiapennit.
r _ AIRHANDLINGINrr(OVERIO,OWCFM) CONSTRUCTION TAX
SignammAR Applicant/Conacto ^DA DXHAUST HOOD(W/DUCT) CONSTRUCTIONTAX PAID:
HAZA RDOUS MAT. LS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rece'
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
gal
Flealth and Safety Code Section25532(a)7 FIEATING UNIT(OVER ID0,0XD BTU)
qYe. r!No
Ill the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air
Quality Management District] BOILER-COMP OHP OR IOO,OM BTU)
4Ycs ❑❑No
haveleadtheh Sou.materlabrequirements under Chapter 6.95of BOILER-COMP(OVER 100,OOD BTU)
the Glifemia Flealth A Safety Code,Sections 75505,25533 and 25537.I /1
understand that lithe building does not currently have.tenant,that it is my NEWRESIDENTIALMECH. 5Q.Fr A ID
responsibility to notify the occupant of the requirements which must be nal •,VO
prior to Issce uanof a Certificate of Gem pancy.
Owner or authorized agent Date 1- ^fUBn 1/
TOTAL: SSIJE
OFFICE COPY