23013 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
"Z Z 3 013 -
0563 G,
reams: one: -
a� V 6C CITY OF CUPERTINO-BUILDING DIVISION. _ A
C.nkractrukhl.ev,: Lie.No: APPLICATION I PERMIT
BUILDINGELECTRICAL PLUMBINC-MECHANICAL. CATEGORY CONTR
A Itect/Engineer. Lie.Nr:
q'j^t •ELECTRIGPERM FEE ,
BUILDING PERMIT INFO
Address:
PERNIITISSUANCE —
LICENSED CONTRACTOR'S DECLARATION
I hereby affirenthat lam licensed under provisions of Chapter9(commene- APPLIANCESRESID L
o
L7s-
Ingwith5eRlon7000).!Diviion3oftheBusinssandProfessio .Cde,and JOB DESCRIPTION
ielslR '
LicenseCass nLi.# b13Z Uj `i
ja�
_Contractor Q
ARCHITECT'S DE LARATIONAMI s 41 Il'y
�qqp±± O I understand my plans aha]beused u public records. OV 1000 AMPS SQ.FF.FLOOR AREA $/SQ.FT.
HE �j Licensed Profeskmal GNSELECTRICA
Gfn 6 O OWNER-BUILDER DECLARATION SPEOLILCIRC TSC
.F I hereby affirm that am exempt fromthe Contractors License Law for the
F & following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP..M OR POLE INST.
l` county which requires a permit to construct,alter,improve,demolish,or repair
file
prlorte its issuance,aborequiresthe applimntforsuch permitto
Vfile a signed statement that he is licensed pursuant to the provisions of the DEVICES
3 ec WIMMIG POOTRI
Contractor'.License Law(Chapter 9(commencing with Section 7000)of Dm- SNL ELECC
si.n3.fth.B.9I e...dProfessioru Cade)orthath.i....ptthercf..and VALUATION
O the basis for the alleged exemption. Any violation of Section 7031.5 by any ,
applicant for a permit subjects the applicant to a civil penalty of not room than OUTLE'ISSWITCt{ESFIXTURES �O 0OQ«.d(J
five hundred dollars($510),
0 I,as owner of property, NEW RESIDENTIAL ELECTR SQ.FT. SID TYPE CONSTRUCTION
p p rty,or my employees with wages as their sole
7a compensation,will do the work and the structure b not intended or offered for
q sale(Sec.7044,Business and Professions Cade:The Contractors License Law
2 does not apply to an owner of property who builds or improves therm,and OCC.GROUP RES.UIVTI'S
whodoes.uchworkhlmaelf orthrough hlsownemployms,provided thatsuch
improvements are not Intended oroffered forsals.If,however the Wilding or TOi
- Improvement b sold within oneyearofcomplellon,the owner-bullderwlli have
tgLlIurden of proving that he did not build or improve for purpose of sale.). QTY; " ' ; P[:I;IMBING PERMIT Y FEE'' FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PFltMIT ISSUANCE
r contractors to construct the project(Sec.7074,Business and Profession Code: -
The Contactors License Law does nae apply to an owner of property who '
j builds or improves thereon,and who contracts for such ptojecb with a ALTER-DRAIN&VENT-WA
cgB(pctorW licensed pursuant to the Contractors License Law. OF SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PRO'('FGT.DEVICE
LES
Owner Date
DRAINS FLOOR ROOF,A SANITARY Y N
N
WRECEIPT
COMPENSATION DECLARATION FD(TURE4 PER TRAP SCHOOLTAX Y N
❑i hereby affirm that I have a certificate of a ccAlft to opy there. ora RECEIPT N
ceriflLab ofWorkeri Compenattonlnurana ora certi(icd copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS
Policy
# C. PARK FEE RECEIPT p
Policy M 1 gS-�'3 -R 1 �6/i GAS EA.SYSTEM-OVER d(EA)
Com anv BUILDING DIVISION FF.GS
Certified mpy is herebyth the ted. F%!1/fp GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFGE
edified copy b(fled with the city Inpec[lon division. �Q7
CERTIFICATE OF EKEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(t'hlisectonneed not becompleted ifthepermlt hforomhundred dollars SEWER-SANITARY-STORM EA.7001117. Date emi t#
($100)or less.)
Icertifylhae In the performance o(thework forwhich thio permit la blued, WATER HEATER W/VENT/ELECTR E FEE- Y_ N_
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date - PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. ecel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hsh.ld become subject to the Wm1ora Compenattm provision of the Labor -FAL:
OI Cmde,you=at forthwith cornplywlth such provisions orthb permitshall be BUILDING 'E
W > deemed revoked. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE'
a I hereby affirm that there is a roostruction lending agency forthe perform ELECTRIC FEE
Z ance ofthe work forwhich this permit is Issued&c.3097,Civ.C.) TOTAL:
V O Lender's Nam PLUMBING FEE
LL I- Lender'.Address QTY. ''. MECHANICAL'PERMIT "i' FEE,' MECHANICAL FE
OW Imrtifythatl havereadthisappliatim.nd statethetheabovelnformation
a bcornect.I agree to complywith all cltyand county ordinances and state laws PERMITtSSUANCE FEES PAID:`
} W relating to building mnatruction,and hereby authorize representatives oflhis
F Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH. Date lies] [#
— (We)agree to save,indemnify an d keep harmless the City of Cupertino P
against liabilities,judgments,mks and expenses which may In anywayaccem AIR HANDLING UNIT(TO 10,000 CFM) SU OTAL:
againstsaid Clty kmrce ofthe sorting of this permit.
( J o ^/S�� AIR HANDLING t)Mi'roVER].,alio CFM) 'CONSTRUCTIONT X
Signature of Applirant/Contactor Dale IXFIAUS'F HOOD(W/DUCT) CONSTRUCTION XPAID:
'HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Cade,Chapter 9.1$and the Date R ei
Fkalth and Safety Code Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) T T
❑Yea No
Will the applicantorfuture building occupant as equipment or devices VENTILATION FAN(SINGLE RESID) ISSUA&(-'1:, T,R
which emlt hazardous air contaminants as defined by the Bay Area Air, �'M 87
allty Management District? BOILER-COMP QHP OR 100,000 BTU)
u�u Yes No FEB _4•
1 IhYe read the hazagoN No.
requlrcments underChapfer 6.95 of BOILER-COMP(OVFR 100,000 BTU) ']A(�2
the California Health&Safety Code,Section 25505,25533 and 75534.] 1a7�7
understand that if the building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.FT `x�qy L
_ .responsibility to notify the occupant of the requirements which mu at be met V 117 VFCUPt:mIIjVU
prior to issuance of a Certifleste of Omrpa nry.
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY