23607 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProtect Idem1ficatlon -- - PERMIT NO.
Budding Addresyy�L/.
�� _ 23607 -
DAIE
e S one:
CITY OF CUPERTINO-BUIIIDIN DI SION t t rolQ ry
c.ntr a �- ue.Nd: APPLICAT N P IT `�C ^'�
BUILDINGELECTRICAL I I3A L CATEGORY CO ��
'Archimet/Eogincer. Lk.No:
t'
' ' BUIGDING'P,ERMIT INFO "
l2TY' E CT ERIvIIT ,'}F.EE ;
Address: I ® *y ❑ ❑
LICENSED CONTRACTOR'S DECLAAATION -
IberebyeffirmthatlamllcmseduMerprov"lone o(Cha)xer9( nIWOa ESRESIDE L JOB DESCRIPTION
Ingwilh Section 70f0)o(Divlsldn 3 ofthe Buelnese and Profess..Code,
homeelsinfullfo and effect.
License Clam Lic. 71Ee rQ
Date Contractor 'W _J
ARCHITECTS DEC RATION 201-1000 - �fb�
aOxp I understand my plans shall lx used as public records. OVER1 ��$114sc iMREA' 'S/SQ.FT.
Licensed Profesamnal - SIGNS EL CAL t LL E' IVt
6 OWNER-BUILDER DECLARATION U E R
�n SPECIAL CIRCUIT/MISC
zp, IherebyatRrmthatlam exempt from Contractors License law forthe
pp following reason.(Section 70315,Business and Professions Code:Any city or A
O 2.r� TEMP.METER OR POLE INST. C
r county which requires a permit to coratrue"ter,Improve,demolish,or repairDATE
amystructure prior to Its issuance,also requires the applicant for such permit to POWER DEVICES '
ruG file a signed statement that he is licensed pursuant to the provisions of the
3wt�, Con/raRore License Law(Chapter 9(reconverting with Section 7000)of Divi- - SWIMMING POOL ELECTRIC VALUA
ti�Oga sion3 oflhe Business and Professions Code)orthat he is exempt therefromand
O the basis for the alleged exemption,.Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURFS
applicant fora permit subjects the applicant to a civil penalty of not more than
five 1,as
nerofthepr. STORIES TYPE CONSTRUCTION
Cc NEW RESIDENTIAL ELECTR SQ.FT.
�n ❑I,as owner ll the property,or my employees with wages r thele sole
C G compensation,wssiness and
Pr andthestmctureie Coor ntracdedo License
ed for
Law
❑ sale(Sec apply044�to Businessdf property Code:Tim Contractors License Law
j�
who ddoes oes
apply torn imserofprusugh who Wilds mporImproves
ovidedrmRuch ' OCC.GROUP , RES.UNITS
whodoementsa not intended
hrough meown e.If,ho however,
the that ing or ,
improvemenbarcnotintenomyearfferedfor sale,If,h ere builderwilI have
., �- '
improvement lesoldwithln oneyearo(completiontMowner-bullderwill have
tlig-Ilurden of proving that he aid not build or improve for purpose of sale.). QTY;'Y', Pt:UMBINQ PERMIT +.FEE FLOOD TONE APN
11 L as,owner of the property,am exclusively wran,Hng with Ikeneed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contra$or's License Law does not apply to an owner M property who
' Wilde or improves thereon, and who contracts, for such pkojects with a ALTER-DRAW&VENT-
WATER BIM
actor(s)licensed t to the Contractor's License Law. TEE,SU I RY'.,
coyt[ under
Se BACK FLOW PROTECT.DEVICE
LJ1 am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N "
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y N
Q1 hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT#
certificate otWorkers'Compensatlonlrntranceora certified copythereof(Sec.
3800,lab C.) GAS EA.SYSTEM-1 INC.40UTLET5 PARK FEE Y N
Policy X RECEPT k
CAS EA.SYSTEM-OVER 4(EA)
Com anv BUILDING DIVISIO FEES
j�Cerifled 0 le ere tum ed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECjrEE /7Ipl'Certified copy Lc filed with the dty Inapectlan division. Iq1.'PyCERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSAMTARY-530RMEA.200FT. DatO'hissection need not be completed Ifthe permit Is torose hundred dollarsWATER HEATER W/VENT/ELI:CTRENERGY PE'I certifythat in the performance ofthe work forwhich this permit is Issued,I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATINGWorkersCompensationLaws,of California. Date PAID
ZZ Applicant NEWRESIDENTIAL PLUM. SQ.FT. Dat
O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workeri Compermation provisions of the Labor OTAL:
CCfA" Code,you most forthwith comply with such provlalons orthls permB shall be
W > deemed revoked.
mBUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tl Iherebyaffrthatthereis a mmtmolonlendingagencyfortheperformm- TOTAL: ELECTRIC FEE
7 Z anceoftheworkforwhichthbpermitlr Lssued(Sce.3097,Civ.C.) r
C1 O Laruire.Name PLUMBING FEE
U. H Lenders Address QTY. MECHANICAL`PLRI4IIT `:FEL ACAETEE
O W Imrtilythatl havereadthis application and state thatlheide veinformation
C Iscorred.Iagreeto comply with all city and countyordlnances and state laws PERMITISSUANCE} relating to building construction,and hereby authorize representatives ofthis -
city to enter upon the above-mentioned property for inspection purposes. , ALTERORADDTOMECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Re ipt#against liabNties,judgments,was and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,ODO CFM) BT AL•,against said City In consequence of the granting ofthis permit' AIRHANDLING UNR(OVER]O,000CFM) TAXSignthan of Applicant/Contractor Date EXHAUSTHOODM/DUCT) TAX AID:HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occdpant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Rec ' t#materialas defined by the Cupertino Municipal Code,Chapter 9.17,and theHealthand SafetyCoderr�Sectlon25532(a)7 HEATING UNIT(OVER 100,0(0 BTU) TO L•❑Yes u No Willtheapplicantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air.
Qua lity Management District? BOILEI-COMP OHP OR 100,000 BTU) P.A & D
ThYes �No - pp
avereadthehaza ousmaterialsrequlremence under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ��/M1 10
the California Health&Safety Code,Sections 75505,25533 and 25534.I 'nAr 199
M
lithe building does not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Ffndfifytheo antoftherequirementswhichmostbemet 'IFFY of Ccrtif ofOavpancy. U�r�...UUUrLLhtll
e authorized agdW Dates - ISSUED BY:
TOTAL:
OFFICE COPY