24102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT N
Build tga 6-foxes j4Uenl.6 Ana 64 9x0111 X 410 2
EmI we:
�.� $'-99 41 CITY OF CUPERTIN4BUILDING DIVISION'
Contractor'. f1�Z
Contranr'.Name: Lk.No: APPLICATION I PERMIT 'L
BUILDINGELECTRICAI PLUMBING-MFGHAMCAL CATEGORY CONTROL N
Architect/Engloeer. Lic,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMIT ISSUANCE .�� $ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION jo
Ihthb iofbmlhatlamgm3afhederproandP ff h onsr9(mmmenc- APPLIANCES-RESIDENTIAL O DESCRR'110N �w
lnenseiSectfon forcers Dlvfect. (theBusinessand ProloslonsC°de,andm ��
license le In full force and effect. PANELS T
License ClassLk.N
Date Contactor UP TO 200 ANUS
ARCHITECPS DECLARATION 201-1000 AMPS
920 I understand my plan shall be used as public records. OVERIIIWAMPS .F VAREA S/SQ.FT.
Limned Professional SIGNS ELECTRICAL C 47P4r
OWNER-BUILDER DECLARATION
5]'ECIALCRXCUIT/M19C
71" Iherebmetudmthat Sectiom31.5,Bfrom
ossa Contractor's License Law fort he
following reason.(Section 700 IS,Business and Professions Code:My city or
O I:. TEMP.METER OR POLE INE.
requires to cauntywhich
q a anynaature prlorto its ie®rance,alsorequtmathe applicantfw such permit to POWER DEVICES
k5 V file a eigned statement that he I,licensed pursuant to the provtsbn of the
Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC �
SOS .Wn3ofthe Bunnessand Pro.I.o Cod,)orthathelsewmpttherefmmand VALUAT6b
Q� the lastsfor the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHIS-FIXTURES s.1 aSOO V4J
Ci Applicant fora permit subjemsthe applicant to a civil penalty of not more than 4w
Anddolof (5500). NEW RESIDENTIAL ELFGTR SQ.7T. STORIES TYPECONSIRIICTION
�n I, d owner o(the properly,or my employers with wage rue their wk
7 taxation,w91 do the wm"nd the structure 6 not intended or offered for
q o(Sec 7044,Business and Pro(esslan Code:The Con rectoes License law
$ does not apply to an owner of property who Wilds or Improves thereon,and
EE who does such work himself orthwgh his own employees,provided that such OCC,GROUP RES.UNITS
Improvement,are not Intended oroffered for sale.If,however,thebullding or T
Impnvementbaoldwithinoneyearofcompldtoktheowner-bulldcrwN have '
t"rdenofpmWng that he dWrwt Wild orlmprove for purpose ofsakJ. QTY, PLUMBING PERMIT FEE FLOODZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PETIT ISSUANCE
mnrractwa to construct the project(Sec 7044,Business and Pmfradona Code:
The Contractor's License Law does not apply to an owner of property who ALTERDRAIN&VENT-WATER(EA)
Wild.or Improve therson, and who contracts for such pipiects with a FEE SUMMARY
CErgIIS(+ctoRs)Banxd pursuant to the Comrsdoes License Law. BACK FLOW PROTFGT.DEVICE
TI am exempt under Sec. B&P C for this rcaaon
OUTSIDE FEES
DRAINS R FLOOROOF,AREA,COND. SANITARY Y N
• Owner R17I'f I
MIO
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o Insurance
of consent to opythure,ora RECEFT N
3800,Labcertificate of Workers Compenatlonlnunnce oracertified ropytheneof Dec. GAS F.A.SYSTEM-1 INC.4 OUTLETS PARK FEE Y N
3600,Lab C.)
Polley N
RDCE][PT
M
CmnyS F.A.FA.SYSTEM-OVER 4(EA) BUILDING DIV
ISION FEES
�Cued
copy is heel with
cit. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑CertNed copy ts filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SAMTARY-STORM EA 200[7. Date Recei tN
(This section-reed net W completed If the permit Is for cass hundred dollars
($100)wfWATER HEATER W/VENT/E.ECT'R ENERGY FEE Y N
I notify
that
rmanth
ceat the perfoce of tAe work for which this penult is Issued,
1 shall not employ any person In any manner an rue to become object to the WATER SYSTEM/TRGTINIG
Workers Compensation laws of California.Data PAID
O Z Applicant NEWREEDENTIALPLMB. SQ.hT. Date - RCceI tN
Z O NOTICE TO APPLICANT.10iter m4drg this Certificate of Exemption,you
should become subject to the WorkerCompensation provbion of the Labor TOTAL:
W Code,you at forthwith romply with such provislwuor this permltshall be BUILDM FEE
W j deemed revoked.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyefirmthat there is a construction lending agency for the perform ELECTRIC FEE
Z assn of the workfor which this permit 6 Weed(Sec.]097,C1v.Q TOTAL:
02 Le.der'.He PLUMBING FEE
LL F- Leadee.Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iartifythatlhavemadthisapphmti°nand statethattheaboveloformation
IL krorrect.I agree to comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize repreacniathrcs of this
Z city to enter upon the above-mentioned property for Inspection Eau rpmea. ALTERORADDTOMECH. Date RCCCI [fF
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities,jadgmnnta,consand expenses which may In any wayaecrue AIR HANDLING UNIT(PO 10,000 CFM) SUBTOTAL'
against dCitylncu era of the grantin of this permli.
[7 / �rI AIR HANDLING UNIT(OVER 10,000CFT1) CONSTRUCTION TAX
Ignature of App nk/Contractor J YDa'te of IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIAL SCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT CM 100,00081U) Date Recei tM
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes No
Will the applicant or tore Wilding oavpantuse equipment°rdevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air contaminants as defined by the Bay Area Air itpp��
Quality Management District? BOILER-COMP DHP OR 100,000 BTU) A D
Yea11��No
1h read the hazar7rous material,requirements undw Chapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the life Health&Safety Code,Sections25505,25533 and 25534. I AFI^ I zl`2 �yas��
understand that if the building does ns.currently have a tenant,that it is my NEW RESIDENTIAL MECH. - SQ.FT a
responsibility to notify the occupant of the requirements which must be met {/VI
prior to issuance of a Certificate ofOccupanry. CITY Ur vvrcti RV
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE COPY
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