23901 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Addreaae 23901
Owner eName: one: -
CITYOFCUPERTINO-BUIL' I DIMS ON
Cen�trAO-ea.Name: / ueNp: APPLICATIO I ERMIT
Yv ` BUILDINGELECTRICALPL GMSC NI L CATEGORY CONTROL
ArchltM/Engineer. Lk.No:
- rY ELECTRI MIT FEE BUILDING PERMIT INFO
Address: PERMITISSUAN 1 �� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION {
[hereby offinn that lam Bernsed under provtaipnmolChapter9( c APPLIA L J BDFSCREPION
ingwithSMion7000)of DiAsion3ofthe Bumuuand Profusl ns rad my
license Is
in full(ores and effect. PANEI9 �O��
Lkeec Class Lk.N
Date Contactor
ARCHITECT'S DECLARATION 701-1000 AMI
q�q�uu OZp Iunderstand my pl...hall be used u public records. OVER 1000 AMT'S SQ.FT.FLOOR AREA
Fi U Licensed Professional SIGNS ELECTRICAL p�1 ® I NL , 1
<<�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C �V
X,s' IherebyafRrm that l am exemptfxem the Contractor's License Law for the g p ^. a. a..�
qqqqqq following reason.(Section 7031 S,Business ami Profesema Code:An city or �" II�.✓B Ntl Illi_ 16.,[I
F f' county which requires a permit to mnstroct,alter,bnprove,demoWh,of repair TEMP.MEI}R ORPOLE INSf. CEE A
any structure prior to It.issuance,also require.the applicant for much permit to ppfyEg DEVICES �� Z
ills a signed statement that he V licensed pursuant to the provisions of the
Ole C cumuct.e.License Law(Chapter 9(commencing with Section 7000)ofDlvi-
3 SWIMMING[VOL ELECTRIC'
elon3pfthe Buainessand Professions Code)ortM1sl M1ebexempt therefrom and L TfONty.,i
O the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES fJ�+
applicantforapermitsubie theappllcanttoad IN.Ilyofnotmorethan IVM1z.
five hundred dollars Mail, /
F11,as owner of the property,or my employees with wages as their mole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
7Q compensation,wlll clothe work send thestructure is not intended or offered for
q sale(Sec 704,Business and Professions Code:The Contractor's Llcaue Law
3� doesnotepplytoan ownerof propertywho builds orlmprovesthereon,and OCCGROUP RES.UNrrS
who doessuchwork himseiforth=gh hisoweemployeu,provided thatsuch
Improvements are nor intended proffered for sale.If,however,thebullding or
Improvement le sold within one year ofcompletion,the owner-builderwlll have
t"rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ypNg ApNr
mu L as owner of the property,am exclusively contracting with licensed PfRMLI.ISSUANCE
ntncton to coutsuct the project(Sec 7044,Business and Professions Code: -
The Contractor's License Law don rad apply to an owner of property who ALTER-DRAIN&VENT.WATER(EA)
Wilds or Improves thereon, and who contracts for much ptojects with a
oj5actorp)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII are exempt under See B k P C for this reawn
DRAINS•FLOOR ROOF,AREA,COND, SANITARY Y N
Owner Date RECEIPT N
_
WORKMAN COMPENSATION DECLARATIONFpTMtES PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that 1 have ocertificatelranof consent to pythem ora RECEIPT N
3800,.ntfiabo(Wprken'Compeuatlonluurance ora certified spy thereof(Sec. CAS EA.SYSTEM-I INC4 OUTLETS PARK FEE Y N
Policy Y RECEIPT M
S F.A.Cam an GASYSTEMAVER4(EA)
pY BUILDINGOINGDDIV ION PEES
Certified copy is heed with the city CREASE/TNDUSIRL WASTE INTERCEPTOR PLANCHECK •E L 1
Certified copy is(Ikd with the city Inspection divlalon. � �J
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SL}yER�SAM.I.ARY-STORM EA 7WFT Da ReCCI IM
(Thlmsectlon need not be completed I the permit le(ororie hundred dollen
(f100)orfeu.) WATER HEATER W/VINO/ELECTR ENERGYF Y N
I cenotrtify that o the person in any
the work so as to
this permit c Ito the
I moil not employ any person In any manner m u to berome subject to the WATER SYSTEM/TREATING
Worlicn'Compenutlon lawn of Callfornla.Date PAID
C) Z Applicant
Z o NOTICE TO APPLICANT.If,after making this Certificate of Ememptlon,you NEW RESfOFNIAL PIMR.
iSQFT. t Recei tN
Fshould bemme.ubject to the Workers''Compereat Ion provisions of the Labor TOTAL:
CC N Code,you at forthwith comply with much provision.or this permit shall be
deer
W
deemed revoked. B G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby a(Brm that there V a corutroctlon lending aganry for the pemorrry !FEES
RIC
ante oftheworklor which this penNt is Issued(Sec.3097,C1v.C.) TOTAL: BING -EE
(.I Lender's Name
IL.F LendereAddress QTY. MECHANICAL PERMIT FEE ANI LFEE
O W Icertlfythatl have read this application and statethat the above information
beermd.I agreeto complywllh all city and county ordinances and mate laws PERMIT ISSUANCE AI} O- relating to building emetruction,and hereby authorize representatives of thioI— Z city to enter upon the abvemartim"property for impM Ion pu rpomes. ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep harmless t Cupertino te Receipt#bllitles, dgm, m ndexpensesw eywayacere. AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL•
aidCi o theg thl It10 AIR HANDLING UNIT(OVER I,000CFM) TRU ON TAX
of Appa o or Date FXIJIUS'I HOOD(W/DUCT) TRUCTI NTAX PAID:
HAZAR 5MATERIALS DI
Will the applicant or future building omu st handta hazardous HEATING UNIT DO l00,ODO BTU)material as defined by the Cupertino Mu palCode,Cha 9.Ij.and the te Recei N
Healthand SafetyCode Sectlon 75533( HEATING UNIT(OVER 10,000 BTU)
Rill
�]No
Ill the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUACEDATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 RITZ
4Yea nI'I No
h.vercadthe hazaidaUs.terialomqufmmcntsunderChapter6.95of BOILER.COMP(OVER 100,DWBN)
the California Health A Safety Code,Sections 75505,25533 and 25534.I
understand thatifthebeildtngdon no cerrently havestenantthat it lmmy NEW RESIDENTIAL MECH. SQFr
responsibility to notify the occupant of the requirementa which must be cont
prior to issuance of a Certificate ofOmupanry. T��j
Owner or authorized agent Data ISSUED BY:_!;r
TOTAL:
OFFICE COPY