20428 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ea Identification PIi1R.WTNO.
a'wamg Aaarea '
s� sSd r 20428
f�f ro ams: �1 one: .
IAA k„4%4 4of, �S'7—I CITY OF CUPERTINO-BUILDING DIVISION
Contra°°r',Name: Lie.N°: APPLICATION /PERMIT
JA BUILDING-MF.CTMCALPLUMBING-MLCIIANICAL CATEGORY CONTROL p
Amhhed/Engineer. Lie.No:
T QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: Rose bL-os m `Jp. PUMTISSUANCE ® El 11 ❑
LICENSEDCONTRACTOR'S DECLARATION
I hereby atlUmthat l am lcensed under provisions of Chapter 9(conemenc, APPLIANCESRESIDENTIAL - TOB DESCRIPTION
Ingwilh Section 700)of Dlvtslon3ofthe Businessand PmfessionsCodq and my - s
license"""D force and effect PANELS
License Class
Date Cmm Contractor CTS DECLARATION —UP TO 200 AMPS
ARCHITE201-1000 AMPS
PQ?Q CO I understand my plans shall be used as public mmrds OVER 1000 AMPS SQ.FT.FLOOR ARBA $/SQ.FT.
E o(/ Licensed Professional SIGNS ELECTRICAL
«<<6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
z1. 4 hercbya((i mthat lam exemptfromlhe Contractor's License Law for the
0 p following reason.(Section 7031.5,Business and Profession,Code:Any city or
P t'sq countywhich requires a permit to construct,alter,Improve,demolish,orrepalr TEMP.METIER ORPOLEINST.
A<`'B 7 anystmc mpriortoitsla .ran ,elsorequU theappha tforauchpermltto POWER DEVIffS
ry1 file a signed statement that he Is licensed pursuant to the provisions of the
Olt,
01 sion3oflhe Buslnessand ProfeContractor's License Law(Cha erg commencln with SecBon7000 of Owl-
XeeiomCWe)orthathelaemmptthemfmmand VALUATION
SWIMMING POOL ELECTRIC I,
the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHES-FIXTURES .5-06) d 0
appilunt fora parent subjects the applicant to a civil penalty of ect morethan
Yeve undred dollars(SM. NEW RESIDENTIAL ELECTR Ff.
�n Las owner of the property,or my employe.with wag.as th,4 sole `•'Q' STORIES TYPE CONSTRUCTION
penation,wlll clothe work and the structure is not Intended or offered for
O sale(Sec.7044 Business erN Professions Code:The Contractors Llunse law
S does not apply to an owner of property who builds or Improves thereon,sand OCC.GROUP RFS.UNITS
who docs such work himselforthrough hlsuwn employees,provided that such
Improvements are not Intended orotfened forsale.If,however,thebulhling or TOTAL: '
impmvenormissold withinoneyearofmmpletion,the owner-bullderwlll have
t11S,buren of proving that he did not build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE IT-OOD/ANE
dAPN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to com uct the project(Sec.7044,Buaineseand Profe.lonsCode:
Th.Contactor'.Lt..law does net apply to an owner of property who ALTER-DRAIN VENT or Improv.thereon,and who contracts toje
for such pcts with a AWATERS
egalf- -n-)licensed pursuant to theC.M.doe.License Law. FEE SUMMARY
Lf I am exempt under Sec. B&P C for this rc.on BACK FLOW PROTECT.DEVICE
EES
Owner a DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N� ,
RECEIPT p
WORKMAN have acSATI OECLARAT N FD(TURPSPRRTRAP SCHOOL TAX Y N
❑1 hereby affirm that I have o Inca ate of consent m opy theure,ora RECE.I
380,Lab ofWorken'Comperwtloninsuranamacertifled ropy ehereo(l5ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab C3
Pollryp — RFCDING PfX
Cram an GAS EA.SYSTEM-OVER4(LA)
Y BUILDING DI VISION FI:IiS
Certified ropy is hercbyth the city GREASE/INOUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copyla(Iled with the city lrupMlon division.
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE I SEWER-SANITARY-STORM EAIWKr. DB[C ReCei tM
(Thiseecd°n need not M complded lithe permit la(Drone hundred dollars . P
($100)or less.) WATER BEATER W/VENT/E.ECTR ENERGYFEE Y N
Imrtlfy that isthe pedormanceofthe work forwhich Wepennitblasued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/.TREATING
Workers'Compensation laws of California. Date PAID
0 Z Applicant NEW RESIDENTIAL I'LMB. SQ.FT. Date Recel t71
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemptlon,you
should become subject to the Workeri m
Copanawlon provlaioru o/the Labor TOTAL:
Code,you=at forthwith complywlth such provisionsorthla permit shall be BUILDI FEE - UO
j deemed revoked.
G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il Thereby affirm that there is a censtmdion lending agency torthe perform- ELECTRIC FEE
D Z sere of the work for which this permit is Issued(See,3097,Civ.C.) TOTAL:
L) O Iandc,.N. PLUMBING FEE
1L F Lendrea Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfy thati have mad thisappllutbnand statethaltheabove information
IL iscorrect.l agree to comply with all city and county ordinances and nate law- PERMIT ISSUANCE FEES PAID:
N relating to building consWctlon,end hereby authorize rcprexntativca ofthle
F titi R
Date ece
he above-mentioned property for Inspection purposes, ALTER OR ADD 7O MECH.
Z city to enter upon t
U) (lac)agree to he a Indemnity an ci keep harmless the City u Cupertino DaP
against labilla.,judgments,costsand a.prn..which may In any way amu, AIR HANDLING UNIT HO 10,000 CFM) SUBTOTAL: .2
agai t Bald Clty In coneap frau of the granting (this permit.
„i/,,, /� AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Slgnaturcof Applicant/Contractor �w JG/t/—e7/_* EXHAUST I I00D(W/DUCT) CONSTRUCTION TAX PAID:
HAURI)DUS MATERIA .I C"WSURE
Will the applicant or future building occupant store or handle hazardous HEATINGUNIT(TO100,000BIL) Date RCCeI tk
'material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: _2
❑ Yes M No
IEtheappliunt orfuturebuildlegoeapantmecqulpment ordevices VENDLATION EAN(SINGLE RESID) ISSL4P�MHJUATE
which emit hazardous air contaminants a.defined by the Bay Area Air AE�
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
Yrs ❑No
have readthehazaN°mmaled.i..qulrementsundcrChapter6.95ot BOILER-COMP(OVER 1W,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I -
understandthatlftheboldingdoesnotcurrentlyhaveatenant,that It is my NEW RESIDENTIAL MECTI. SQ.Fr.
responsibility to notify the occupant of the requlmments which mu at be met �I of r( Itlno
priortoi...rrcofa CertificateofOccupancy. InP
Ownerorauthotludagem Data ISSUED BY: �V CL
TOTAL:
OFFICE COPY