22146 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Ild K )—,P dswx& Ad� Z Z 14 6
nJ/ Anne: ee // one:
�10N.(J /VOGN� 9'&—'16 CITY OP CUPERTINO-BUILDINGDIVISION �'�.
ContmnnraName: Lie.N.: APPLICATION /PERMIT
N11 BUILDINGELECTMCAL.PLUMBING.MECHANICAL CATEGORY CONTROL It
Architect/Engineer. Lie.N.
A BUILDING PERMIT INFO
QTY ELECTRICPERMIT FEE
Address PERMITISSUANCE 11 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afftrm that l am licensed under provtdons of Chapter 9(commenc APP11ANCES-RESIDEMML JOB DESCRE'TION
It---i in
70W)ofd ff.on3of/he Businenantll'r.fesslonsCode,and my
iigwithl on7orceandeffect. PANELS
/r License Chea Lisa
Date ComrActor
ARCHITECTS DECLARATION 201-1 WOAM '
I understand my plane shall be used As public nmrds. OYER I WO PS �.FT.1FLOOR AREA - S/SQ.Ff.
'r4 Licensed Pm(esshmal SIGNS ELECTRICAL
"a OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
z I herebyaffi.that P am exempt franthe Contractor'.License Law for the
O
following reason.(Section 7031.5,Business and Pm(essions Code:My city or�. TEMP.METER OR POLE INST.
countystmciu whichrequires
to is perMllomrutmuices alter,theapmcant fm
permit to
anystmdure pdortolta,auance,also requlreathcappBant far such permit to pOWEB DEVICES
file a signed statement that M,licensed pursuant to the provlslons of the —
3µ Contractor'sLicense Law(Chapter9(comr,mcingwith Section 7000).(Divi- SWIMMING POOL ELECTRITW
BO ION
U�AqTc)
Hsion3.fthe Bualnnsand ProfessionsCode)orthat helaexempttherefmmentl VALUATIONW
Sn......771777 the basis for the alleged exemption. Any violation of Section 7TI S by any r OUTLETSSWITCI{ISFIXI'UR W
applicAnt fora permit subjects the applicant m a civil penalty.f not mom than x-
ryp It-
five ns ad owner
lars ofthe 0. SQ.IT. SIDWF;1 TYPECONSTRUCTION
dl as owner of the property,or my employees with wages a their outs ?``EW RESIDENTIAL ELECTR
compensation,will do the wort,andthestmcture is not intended or offered for
sale(Sec 7014,Bustnas and Professions Code:The Contractors License Law /
does not apply to an owner.(property who Wilds or improve thereon,and OCC.GROUI RES.UNITS
whodoessuchworkhimseiforthrough Msownemployen,provided that such
Improvements are not Intended oro((ened for ale.If,however,thebulldingor TOTAL:
improvement,sold wlthinoneyearofcompteion.theowner-buRderwill have
tl)S}xrdenofprohng that he did not build orimprove for purposeofsale3. QTY. PLUMBING PERMIT FEE pLOOD7DNE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
centracton to corstma the pmject(Sec 7014,Business and Professions Code:
The Contractor's License Law don not apply to en owner of property who ALTER-DRAIN&VENT-WATER(EA)
buildsorImproves thereon, and who mnlracte for such plojecia with a FEE SUMMARY
cyactor(s)Bcensed pursuant to the Contractor's License Law. gAQ((pLOW PROTECT.DEVICE
I am exempt under Sec. B&P C'for this reason
'
OUTS I DE FEES
Owner Data
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y N
WORKMRECEIPT s
AN COMPENSATIONDECLARATION
❑I hereby affirm that 1 have a certificate of consent to..I . ' a FIX'NRES PER TRAM' SQi00L FAX Y N
RECEIPT M
artlflateo(Worken'CompevatlonIroranm ora certtfbd ropypy thereof(S .
3800, GAS EA.SYSTEM.1 INCA OLI LETS PARKFEE Y N
4
Conn ^ DING rrp
CAS EA.SYSC[2d-0VER d(EA)
Com y BUILDING DI VISION FEES
fCertlOed copy,hereby fumished.
Certified copy is filed with the city Inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EVEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWER-gAM•p,V2Y-yIDRM EA 2WFT Date RCCCI tM
Crhlssection need An(h completed tithe permit,for ane hundred dollars D
($1 ramify
that
WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Ice Am thato the person in
work.Astobforwidch thispesubjec blued,
!Whale not employ any person In any runner ao v to become subject to the WATER SYSTEM/TREATING
Workers Compensation laweo(Gllfonh, Date PAID
—
Z Z Applicant NEW RESIDENTIAL PLMB, SQJT. Date Recel tN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould become subject to the Workem'Compematlon pnmblons of the Labor TOTAL:
N Code,you at forthwith comply withauch prov,lom or this perrNt shall be FEE
j deemed revoked. G
LU
C rCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there,a mnsbucteon lending agency forthe perlorns, ELECTRIC FEE
Z anm ofthe work for which th, rm „
peitsued(Sec.3097,Civ.C.) TOTAL:
(—) 2 Lender,Name PLUMBING FEE
LL ~ Leaders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certllythatl have read this appllationand Aatethatiheab.v.Information
4 uoxrnxt.Iag.m complywithall city and ca.myoNloances and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building constmetion,and hereby authonxa represenativee.fthi.
ZT, city to enter upon the above-mendmod property for inspection purposes. ALMORADDTOMECH.
Mr)agree to save,indemnify an d keep harmless the City of Cupen ino Date Receiptfl
against liabilities,pdgments,mYe and expenses which may In any way accrue AIR HA LADLING UNIT(TO 10,000 CFM) SUBTOTAL:
against sal Cuty mnaequence It.the granting of thi AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST I IOOD(NI DUCT) CONSTRUCnON TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppllantorfutun building occupant store or ha Ad to hazardous HEATING UNIT(TO 100,000 BTU)
material.,defined by the Cu pertino Municipal Code,Chapter 9.1 7,and the Date ReCei til
Health and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,OW BTI) TOTAL:
❑Ye No
Will the applicant or tun Wlldlng omnpast use equipment or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contaminants a.defined by the Bay Area Air
Ilty Management District? BORER-COMP QHP OR 100,000 BTI) �y
hYYe. N No �o
ave read the haza❑ous materia,requirements under Chapter 6.95 of BOILER-COW(OVER 100,000 BTI)
the California Health&Safety Code,Sections 3550.5,25533 and 75534.1 nn " O �M
understand that if the building does not currently have.tenant,that it is my NEW RESIDENTIAL MECH. A SQJT. '{ 99I
responsibility to notify the occupant of the requirements which moat he met
prior to Issuance of a Certificate of Occupancy.
Owner or aulhMud agent Date ISSUED BY
TOTAL:
OFFICE COPY