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Building Protect Identification
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PF:ItMIT NO.31
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APPLICArUSIMMM—Ar A
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CITY OF CUPERTINO-BUILDING'DIVISION .
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Contrct9r'aN� u. o:
APPLICATION /PERMIT -
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CATEGORY
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BUILDING-ELECTRICAL rLUMBING-MECHANICAL
Architect/Engineer. Lic.
,,{: -:BUILDING PERMIT INFO
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'.,Q •.,tt �' FEE
(( t ,ELECTRICIPERMIT ,. t'
Addreas: i,
ERh9TISSUANCE i�
CJI
LICENSED CONTRA OR'S DE�RA�Ta
erprovMf apse(co
MPLIANCESRESIDENMLIngwlth5en1on7000)of
LIherebyeffirmthatlamBcensedu
Dlvlalon3 olthe uelnesealon e, and
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'license sac1. hmsBfortnand k.#
License Cures Lk.p
ANQS _ �a
(.11
���w �A �fQ�'/
�lf/�rl `lir Y/��R
Date Contractor
— UP TO 200 AM5
ARCHITECT'S OBCLARATIO
201-1000AMPS
SQ, Fr. FLOOR AREA
S/SQ, FI,
((YY
I undergo my be l�'1, OVER IWO AMPS,
nd pMnahaIt used as publicremrd
Licensed Professional //'-�e�1-
SIGNS ELECTRICAL
I D�eq/VD
OWNER -BUILDER DECLARATIO
I hereby afflm that l am exempt from the Contractor'. License Law for the
SPECIALCIRCUIT/MISC -
.
I
f00uwing reason.($codon 70713, Business and Professions Code: Any city or
TE(•(p METER OR POLEiNSf.
cauntywhichrequimaper ttommtma,altegU pmve,de=lbh,orrepair
anystructure prlorto its issuance,alsorequlr sthe applicantfor such permit to
POWER DEVICES
Ole a signed statement that he M licensed puruant to the provisions of the
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Contractor's License Law (Chapter 9 (commencing with Section 7000) of EDO-
SWIMMING POOL ELECTRIC
- V A N
don3ofthe Busineasand ProfcoloeCode)orthatheleaxempttherefroman
the baso for the alleged exemption. Any violation of Section 7031.5 by an
OUTLETS swiTCHFSFIXfURFS
applicant fora permit subjects the applicant to a civil penalty of not more thal
as
five1,.s ed owner of the prOD.operty,
1, owner of the property, or my employees with wages Their eine
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPECONSfRUCTION
ou will do and the s bnot r
mm(Sec.
orofferedLaw
Ton,
Busineshe s and Pr Code: Comrade.
sale( Sec apply an tf Code:The ContractorsI slaw
does not apply to ownerproperty improves hare
RFS. UNITS
thtandwhod �chOCC.GRO(ll'
suchnee
r hiwfforth=ghhis nempoyi sp -
or aw.
whom In not Intended
Improvement=k1 intended oroffnred for Bale, If, however, thebuildingor
If,he supra ebuilding or
TO a/
Improv,orgat eold wgthinone yearo(comp:dlo,theawner-bu0derwillhave
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of proving that he did not build or Improve for purpose ofsale.).
QTY, t^.' I PLUM BING PERMIT '� FEE'
FLOOD NNE
APN
Xden
as owner of the property, am exclusively contracting with licensed
PERMIT ISSUANCE
tractor to construct the project(Sec.701q twomessaed Pmfesslons Code:
noContractor's License Law does not apply to an owner of property whoALTERDRAIN
--
&VENTWATER (EA)
'FEE SUMMARY
builds or Improves thereon, and who ro muds for such pkojects with a
m,R[fact.r(s) licensed pursuant to the Contractor's License Law,
BACK FLOW PROTECT. DEVICE
13F FITS
I am exempt under Dec. B & P C for this reason011THI
SANITARY Y_ N
Owner DatDRAINS FLOOR, ROOF, AREA, COND.
- e
WORKMAN COMPENSATION DECLARATION
❑[ hereby a(flrm that I have • certificate of consent to ora
Fp(gvRpg PER TRAP �
RECEILef N
SCHOOL TAX Y ' N
opytceure,
Workers'Compensationlnunnceoracertifled ropythereo((Sec.
RECEIPT N
PARK FEFE Y N
38W,abof
Lab C.) GAS EA. SYSTEM-11NG0 OUTLETS
Polic3500,
R[:CEQ"f N
Com nay
Cum
GAS- Ep, SYSTihf-0VER 4 MAI
BUILDING DIVISION FEES
copy be hedwithreby the cityad.
Certified
Certified copy be filed with the citylnspectlon division.
CREASEANDUSTRI- WASTE INTERCEPTOR
PLANCHECK FEE
TJ J
CERTIFICATE OF EXEMPFION FROM WORKERS'
GREASETRAP :
PAID 6
COMPENSATION INSURANCE
(Thissectmnneedrat becomplated lithe permit lstorone, hundred dollar
SLIVER SANITARY -STORM EA. 200E .
Date Recel 1
ENERGY FEE Y
^/
($10(Oculess.) WATER HEATER W/VENT/ELECTR
certify rtify that In the performance ofthe work for which two permit is Daunt,
I
shall not employ any person In any manner so as to become subject to the
WA.LHR SY5fEM/TREATING
10 N L
Worker' Compensation Laws of CobfomM. Date
PAID
Applicant -
NOTICE TO APPLICANT: IO after noticing this Certificate of Exemption, you
NEW RESIDENTIAL I'LMB. SQ'�'
Date Recei t#
TOTAL: '
should becomesubject to the Workers Compeoaatlon provisions ofthe Labor - -
Cade, you must forthwith comply with such provisions orthls permit shall ba
BUILDING
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE AA
Ihambyaffirm that there's a mnsgructLending nding agency for the perform
TOT /
_
ELEC'T'RIC FEE
ance of the work for which this permit Is Issued (Set 3097, Cls. C.)
-'
PLUMBING FEE
Lender's Name- -,
Lender's Address'
QTY:, MECHANICAL'PER"MiT �' !� FEE
MECHANICAL FEE
I mnifythat l have read this application and nate thatthe above Information
FEES PAID:,
is rorrect.Iagem to comply with all city and county ordinances and slate laws mzifLTISUANCE �� -
relining to building construction, and hereby authorize representatives of this
,
city to enter upon the above-mnnBoned property for inspection purposes.
. d keep
ALTER OR ADD TO MECH.
Date Reeci Pf#
(We) agree to save, Indemnify an harmless the City.. Cupertino
ago int llabilltleq;udgmgm, cosxand expenses which may In any wayattrue
AIR HANDLING UNIT (TO 10,000 CPM)
SUBTOTAL'
ago Wt said City in consequence of the granting of this permit.
AIR HANDUNC UNIT (ovFx 10,000 CFM)
CONSTRUCTION TAX
ignature of Appllant/Contractor Date
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID: '
' HA7AR DOUS MATER IALS DISCLOSUR E
Will the applla nt orfuturo building occupant store or handle hannfous
HEATING UNIT (TO t OO,ODO BTU)
Date Receipt#
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
TOTAL
Health and Safety Code Section 2S32(07
❑ Yes r] No
IDEATING UNIT (OVER 100,000 BTU)
ISSUANCE DATE -
Will the applicant or future building occupant use equipment or devices LotVFNULATION FAN (SINGLE RESID)
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District?
BOILER -COMP DHPOR 100,000 BTU) -
Yes ❑No
have mad the hazardous materials regWmmenM underChapter 6.95 of
BOILER-COMP(OVER100,000 BTU)
n p 8
P A
the Calffomfa Health &Safety Cod, Scow. 25505,25533 and 25530, 1
understand that lithe building don not correctly have a tenant, that it M my
responsibility to notify the occupant of the requirements which most be out
NEWRESIDFNTIALMECH: SQ.Ff
•JA.'v � 24 1�'�'2
s7 s7
prior to issuance of a Certificate of Occupancy.
Gil I low
Owner or authorised agent Date
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ISUEDBY:_
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OFFICE COPY
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