23159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Budding AddmBuildin Project Identification PERMITNO.
o -7 ? 5 �� p� 23159
e ame: APPUCA IION suaw iTALA
'S61JG5 VV,, AI P—y 3'0-1,S- ( CITY OF CUPERTINO-BUILDING DIVISION 1 �
Contractor's Na me: Lic.No: APPLICATION / PERMIT l
e'f4 IQ 5-S-44 y BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Iters/Engineer. Llc.No:
QTY ELECFRICPERMIT FEE BUILDING PERMITINFO
Add-,- D PERMITISSUANCE ❑ 1:1 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby afflrm that l am lfcensed under provisions of Chapter9(comment APMANCESRESIDEMIAL JOB DESCRIPTION
Ingwith Section 7000).1 Division3ofthe Businessand PmfesslonsCode,and my
Intense is in full force and effect. PANELS
License Clan Lie#
Date Contractor
—LM IQ 200 ANTS
ARCIMTECP5 DECLARATION 301-1000 AMPS
ce ZO I undersgnpx&xa Qp86eu bile s. OVERIOOOAMPS �F�OOR( A, 5/SQ.Fr.
k �j Licensed Prof✓essiioonaall41 /Y_ SIGNS ELECTRICAL Rte"\w,
<<<� OWNER-BUILDER DECLARATION / �
�n 6 SI'ECIALCB2CNT/MLSC
ZF, owing rasondthcUam31.5,Blro ossa Contractor's License Law fort he ^
following recon.(Section 7031.5,Business and Professions Code:Any sty or /
O E.e
TEMP.METER ORIOLE INS(.
< DISTE
any stmcturetatemadthata@e,ab.requbestheatothe rewbihpermite POWER DEVICES
O c O file a signed statement that het licensed pursuant it the proNsl00)of the
3 i7 C.ntnctor's License Gov(Chapter 9(commencing with Section 7000)of Divl- SWIMMING I00L ELECTRIC
F, Sion 3 of the Business and Profeelom Code)or that he Is exempt therefrom and VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLE7SSW17CF3F_SFl%TURES lJ 0 Oa
« applicant for a permit subjecathe applicant to a civil penalty of not more than
a five hundred dollars($500).
1,as owner of the property,or m employees with ova es act their sok NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑ P Pent. Y erne Y B
compensation,(Sec. K will B..do the,aa and rkxf.lonand the stmcture h no.,dreaded or offered for
O ale(Sec.7044,8uslneso and Professbro Code:The Contractole Llcerae Taw
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
m
c who does such work himself orthugh his own employees,provided that such
lmprovements are not Intended oroffered fwsale.If however,thebuliding or TOTAL:
Improvementis oIdwithinoneyearofcompldiogtheowner-buederwRlhave
thL12tudenofprovingthat he did not Wild.,Impreve for purposeofsak.). QTY. PLUMBING PERMIT FEEFlAO ZOD AAPN
Lj L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sm 70K Business and Prv(etsiorn Code: PERMIT ISSUANCE
The Contractor's License law does net apply to an owner of property who
'soALTER-DRAIN&VENT-WATER(EN
Wilds or Improves,thereon, and who contracts for such pWieaa with a
cq➢tt a (a)licemed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B&P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N
Owner ouTsipr Mi
Date RECEIPT N
WOR1Q,fAN COMPENSATION DECLARATION FD(TURES PER TRAP SCIiOOL TA% Y— N
❑I hereby affirm that I have a ceni0cate of consent to sell-Insure,m a RECEB'f M
4 wniflcmeof Workers'Comperaarlonlro mncemaceniffed mpythereof(See. GAS EA. INCA 3800,Lab C.) PARK FEE Y N
Policy Is GAS G.SYSTEM-OVER RECER'T#
Com any OVER 4ILIA) BNLDINC DIVISION FEES
Certified copy b herebytume cityecl. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F-1 Certified copy h(lied with the tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWERSANTTARYSTORM EA 20OFT Date ReceI t#
Rhb section need sea be completed lithe permit b(Drone hundred dollars
(5100).r1ess3 WATER HEATER W/VENT/177 TR ENERGY FEE Y N
Illnit that In employ
he any ermanceny he worknorner so
become
permit Is booed, —
L 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
O Z Applicant
Z O NOTICE TO APPLICANT:R,after making this Certlflcate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Fr. Date Reeei t#
Hshould become subject to the Workers'Compemation provisions of the Labor 70'PA
CCN Code,you must(orthwilh comply with such provisions or this permit shall be r1
W j deemed revoked. BUILDING E
CL G f
CONSTRUCTION LENDING AGENCY mSEISMIC FEE
ce
I hereby affirthat there i aco®t UIssu 097
lending agency the perform,
Z onof the workforwhich this perMthbsued(Sec.3 ,Civ,CJ TOTAL: ELECTRIC FEE
U O fender's Name PLUMBING FEE
LL U I<d car's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W orrect Iagrehavereadthbappllcitlonanddc adacounty
ordinances
ndmatelaws
4 is correct. Wilding complywRh alnd hereby
muntywdinanasand mate laws I'FAMITISSUM'CE FEE$PAID:
} N relating to Wilding comtronion,and hemby authotlu representarivn of this
Z city to enter upon the above-memloned property for Inspection purposes. ALTERORADDTOMECH.
— Me)agree to save,Indemnify an d keep harmless the City of Cu penin Date Receipt#
against liabilities,Judgments,costs and expenses which may in any way accrue AIR HANDLING UNIT OO 10,000 CFM) SUBTOTAL:
ag.imt said City in conaLgYen ofth anon ofthls permit.
/ 0 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Slgnalure of AppBram/ContractorDate IXHAusr Hoop pY/Duel) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllcant or future building ocevpantstoreorhzndle hazardous HEATING UNIT(TO 100,000 BTU)
material a,defied by the Cupertino Municipal Code,Chapter 9.1 7,and the Date Recel t#
Iieafth and Safety Code Seaton 25532(x)? HEATING UNIT(OVER 100,"BTO
❑Yes r]No TOTAL-
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air pp ff/�y9
Quality Management District? BOILER-COMP QHP OR 100,000 BTO PA Y.#
4 Yea n No
havenla the Nazar et Code,Sections
25555533 aChapter.1 of BOILER-COMP(OVER100,000 BTO
the Glifornfa limlih&Safety Code,Sections 25505,25533 and 25534.7
understand that if the building does not currently have a tenant that It b my NEW RFSIDEN71ALMECH. SQ.FT. ��� O6 I��Z�
responsibility to notify the occupant of the requfrem.nts which most b,met
priorto Issuance of a Certlfi atte of Occu anry.
IMa bL f-69 CI-fY r-UHLHUNU
Owner or au honsd agent Date
TOTAL: ISSUED BY: ,,
OFFICE COPY