20665 1 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
_ nBd,Fo d8o,1 20665
,{ _(/y-y CITY OF CUPERTINOBUILDING DIVISION _ apo
4 Contractors Name: LIcNo: APPLICATION /PERMIT
BLRLDING-ELECTRICALFLUMBINGMWC LAICAL CATEGORY CONTROL#
..Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT .,-FBE BUILDING PERMIT INFO
Add... PERMITISSUANCE ❑ ❑ ❑
—LICENSED CONTRACTOR'S DECLARATION
I hereby Bcen.edunder provisions
essand PmftWpteCde,.cenc MPLIANCESRFSIDEN7IAL JOB DESCRIPTION
Ingwhh SeNon to.of d effeon3oflhe Buslnesaand ProfeaelonaCode,and my \��
license le I.hu s fortu dna erred. PANELS V 1
License Clava ontr
Date _-Contractor UP TO 200 AhTS
ARCHITEC175 DECLARATION MI.10B)AMPS
Ob I understand my pWtu shzl be used as public records JOVERIODOAMPS SQ,FT.FLOOR AREA I $/SQ.FT. ,
b(C� Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SI'ECIALCItC MLSC
7F Ilia��� Ihercbyafflrmthatlameaempt fromthe Contractor'eLicenee lJw(or the
following reason.(Section 7071.5,Business and Professions Code:And or
F41•, countywhichrequimsapermlttommtmdaltegimpmvedennlbh,orrepalr IIIdP.METFROR EI
.<� anyslmoure pAortolleL ance,alsorequlmstheapplicantfm.uch permetto POWER
tJ Ole a signed statement that he V limned pursuant to the provbioru of the
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SIAWANG W 7
f„ O aon3o(the Bus nand Profemiam Code)orthathehexempitherefromand VALUATION
`m' the basis for the alleged exemption. Any violation of Section 7031.5 by any
OSAapplicant for a pemet subjects the applicant to a civil penalty of not=mthan OUTLE155W1 S ES
$
it
undred dollars%SOD. NE D LELEC
�n a.owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
C m nsatlon,w0ldolhe work,and thestructure isnot intended or offered for
$' sale(Sec.7644,Business and Profession Code:The Contradoes Dame law
docs notapply to an owner of property,who Wilds or improves thereon,and OCC.GROUP
0.0. whodoeaeuchworkhimselforthroughhieown employee.,provided that such RFS.UNITS
Improvements are not Intended oroffered for sale.If,however,thebuilding or TAL:
Improvement b sold within onyearofcompletlan,the owner-W llderwill have
til*rden of proving that he,did out build or improve for purpose of sale.). QTY. P MBING PE RML FEE n, FLOOD ZONE APN
(JL as owner of the property,am exclusively contracting with licensed PERMIT 1 UANCE ,v
contractors to construct the project(Sec.7614,Business aProfession Code:
The Contractor's Limnse law does not apply to an owner of property who ALTFA.DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptujects with a
mp(rador(s)licensed pursuant to the Contractor.License Law. FEE SUMMARY
0I am exempt under Sec B& P C for this reason BACK FLOW PROTECT.DEVICE
fiES
Owner Data DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N� _
RECEIPT x
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have o Insurance
nfra c of consent to op Chemo,ora RECEIPT x
certlBcab ofWorkem'CompenaHonlnunnceoracertified copythemof(Sec. GAS F.A.SYSTEM-I INCA OUTLETS
3xlic Isis CJ PARK FEE Y_ N_
Policy RFJCECAS-EA.SYSTEM-OVER MM DING TN -
Cany BUILDING DIVISION I'I:ES
amMCerllfiea copy is hereby filed
the city GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANIfARYSIORMEA200FI Dale RCCCI
(Thlsseciion need not be completed Bthe permit Is forone hundred dollars ptq
(5100)orlees.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify that in the person
many he manner
so which as to
permitI.cuo the
I shall not employ any person In any manner at az to become cubktt to the WATER SYSTEM/,TREATING V
Worker%Compenation laws o(Call(omla, Date PAID
O Z Applicant' Date RCeel tN
Z Q NOTICETO APPLICANT.If,after making this Cortlirzte of Exemption,you 'NE'W RFSIDENT[AL PLMB. SQFT.
should become.ub)ed to the Workers'Compensation provision of the Labor TOTAL:
(/) Coda,you=at forthwith complywRh such provislonorthb pemet shall be
j deemed revoked. BUILDIN
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there b a construction lending agency forthe perform TOTAL: ELECTRIC FEE
7 Z ante ofthe work forwhichthle,permit b lssued(Sec.W97,Clv.C.) �0
LL O Leedce.Name PLUMBING FEE 0 0
0-
LL I<ndcrc naareea QTY. ' MECHANICAL PERMIT FEE MECHANICAL FEE
O W IceAffythailhavereadthl.appllmttonanddatethattheabovelnfor tion
bmrrect.l agree to complywith all cityand county ordinances and gate laws PFRMITLSSUANCE FEES PAID:
} IL relating to building construction,and herebyauthoroempresentativeso(this -
F- N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Recelpt#
V .gains bNtiea,}sdgments,coa[san ,passes which may In anywayamme AIR HANDLING UNIT(TO 10,600 CFM) SUBTOTAL:
0
.gal n id City in mn.7 aft no ting of tNe permit AIR]iANDWNG(INR(OVER l0,000CFM) CONSTRUCTION TAX
r 7f
Signatureof Appliant/Conradar 00" IDaid EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(10 100,000 BTU) Date ReCei tM
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z,and the ads
Health and SafetyCode�+-S�ect1on2553T(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL
�y
qYes u No
lll the applicant or fewer building occupant useequipment ordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
.•-ray., which emit hazardous air contaminants as defined by the Bay Area Air MUD
�•' Quality Management District? BOILER-COMPOFIPOR100,000BTU)
i t Yes No
r haveread the haze Rs materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
v'1he Ca hfornla Health&Safety Code,Section 25505,25533 and 25534.1 Jui U 5 l�eJ
understand that lithe building Hoes notcorrenllyhave atenanpthat lliamy NEW RESIDENTIAL MECH. SQ.FT '
responsibility to notify the occupant of the requirements which moat be met
prior to issuance of Certificate of Occupancy. —!—
,
Owner or authorlacd agent Date - ISSIJEUBY:
'TOTAL: I
OFFICE COPY