23121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PFUVFENO.
Building A�,221 1-t V;R} 23121
,nvnxr.Name:
siaso CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
BUILDING-E.ECTRICALPLUMBINGMECHAMTEG
CAL CATEGORY CONTROL#
/Engineer. Lle No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. I'QtMITISSITANCTi `�� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby.
that l am Licensed under provisions of Chapter 9(commenc APPWANCESRESIDENIIAL J D6SCRR'IlOfff...777
It...11.full force andeffect. fthe Businessand Pro(esalonaCade,and my e� ^
license Is In full force and c.0 PANELS LVL IVB
License CUssConte
Date Contractor
ARCHITECTShallbeused
as public
701-1000 AMPS
Po±niO ZpC [understand my plow shag be ueedsspubecremrds OVER IOW AMPS SQ.Fr.FLOOR AREA 5/SQ.Ff.
Eo(/ Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECALCIRCUIT/MISC
z a Iherebyaffirmthal l am exempt from the Contractor's License Lew for the
following reason.(Section 70)15,Business and Professions Cade:Any city or
Fp. TEMP.METERR POLE INST.
� muntywhi&mqulreeapert tromrotruct,.Iw,fmpmve,d,.Il h,orrepalr
anystrocture pdorto its hsuance,aisorequirestheappliant forsuch permit to yPOWER DEVICES'w y file a signed statement that he is licensed pursuant to the prevalent of the
3µ0� Contractor's License Law(Chapter 9(mmnenciag with Section 7000)of Divi.
SWIMMING POOL ELECTRIC
Mara ofthe Buetness and Penfessimu CodOmthat he is exempttherefromand _ w �VALUA`TIO)Lo��
O the basis for the alleged exemption. Any violation of Section 70115 by anyTErLE13SNTTCHFOTURFS
appEant fora permit subleds the appllant to a dWI penalty ideas morethen E4J
Bvghundead dollars($500). NEW RESIDENTIAL ELECTR_SQFI'.
�n u I,as owner of the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
�P mmpen°a.7094
I awilldothe work and the structure is not Intended or offered for
Oaale(SecBusiness and Professfmu Code:The Contracts'.License Law
3 does not apply to an owner of property who builds or Improves thereon and _ OCC.GROUP RFS.UNITS
dace such work himself or through Ms own employees,provided that such
Improvements are not intended oroffered for safe.If,however,thebuilding or TOT L
Improvementbsaidwithinoneyearofcomplel Nthemner-budderwBlhave
t ecienofpmvfng that he did not build or improve forpurposeofsale3. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj 1,as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7004,Business and Professions Code: PERMIT ISSUANCE
The Contactor'.License Law does nor apply town owner of property who
builds or Improves thereon, and who contracts for such pTjecv with a ALTER-DRAIN&VENT-WATER(EA)
adorts)llcamed pursuant to the Contradoes License Law, BACK FIOWPROTECT.DEVICE FEE SUMMARY
I am exempt under Sec B 4 P C for this reasonOUTSIDE
Owner
DRAINS R FLOOROOF,ARG,CONED. SANITARY Y N
Date RECEIT#
WORKMAN that COMPENSATION OFCLsent he N FIXIIIRESPER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have a artNate of consent
m adf-insure,ore RECEIPT N
certificate of Warkea'Comperuatlon Insurance or a certified ropy themchsoc. GAS PA.SYST'FM-1 INCA OUTLETS PARK FEE Y N
Policy#800 C.)� C _ -7�� _ RECEIVE
Corry p GAS G.SYSTEM-OVER 4(EA)
Com v 271 bCN C -L, arS BUILDING DI VISION FEES
rtRied copy hereby with Ns he . J GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CertNed ropy lit filed with the city Inepeition division.
CENTIFIGTE OF MGxf"ION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SFORM G 700FI Date RCmi t#
(This section need nae be completed if the perro t is forane hundred doll..
0100)offess.) WATERHIEATERW/VENT•/ELECTR ENERGYFEE Y N
(certify that in employ
he any domain an thework so as to b co permit
subj c issued, —
1 Whale not employ any person in any manner w es to become subject to the WATER SYSTEM/TREATING
Workers'Compensation[as of California.Date C PAID
O Z Applicant NEW RESIDENTIAL ELMS. SQ.FDate Recce t#
Z O NOTICE TO APPLICANT:If,after nuking t his Certificate of Gemptlon,you
Fshould become subject to the Wmicars'Compensation pem,ihx.oflhe Labor TOTAL:
WW Cade,youroIfarthwftL mmpywfth Wuchpmvbt...rmlepemdt Wh.Eba
> dramed revoked. BUILDING FEE
f1 p coNSTRUCTION LENDING AGENCY SEISMIC FEE I
I hereby affirm that there is a construction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec 3097,Civ.C.) TOTAL:
U 0 lander'°Na nc PLUMBING FEE
LL F Iandar'9Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I mrtiythat l have read this appliatlonand state thatthe above lefornution
6. ismrmt.lageeetocomplywlth.Odtyandcountyordlnancesand Aetelaws PERMIT ISSUANCE FEES PAID:
W relating to building covteuctlon,ad hereby authorize representatives ofthis
HZ city to enter upon the abovementioned property for impecdon Purposes. ALTERORADOTOMECH. Date Recei t#
— (We)agree to save,indemnify an d keep barred—the City of Cupertino F
against liabilities,7adgerent,costs andexpensss which may lnanywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
//
.gzlrut Id Cit IncomequenaofNthegrantingofthlspertnit.
//, 1, 000
/ AIR HANDLING UNIT IO, CFM) CONSTRUCTION TAX
Igeumre of ppllant/Contractor Date EYfgAl1ST HOOD M'/DIKT) CONSTRUCTION TAX PAID:
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 Code,Chapter 9.IZ and the Date Recej t#
Health and Safely Cody Section 75537(a)7 HEATING UNIT(OVER 100,000 BTI. TOTA
❑Yea �No 0
WiYes eappliantarfum.r ulldingmmpantamcquepm' tordaAca VENILATIONPAN(SINGLERFSID) ISSUANrr DATE
which emit haaardous ab contaminants as defined by the Bay Area Air v
Quality Management DLatrid7 BOILER-COMP QHPOR 10Q0fD BTU)- p11 P,
4 Yes No 7
have read the hexa ous materials requirement underChapler6.95 of BOILER-COMP(OVER 100,000 BTU)
the California l lealth A Safety Code,Sections 25505,75533 and 75534. 1 �C 1
t 8 y 1
and e..ad that if the bu llding does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FI
responsibility to notify the occupant of the requiecmenwhich must be met ;INV
prior to Issuance of a Grtificataaf Occupanry. VY Gup�H
�JC�
Owner or authorized agent Data ISSUED BY
TOTAL:
OFFICE COPY