23077 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildh Pm en Identification PERh0TNO
T111ding,dress:Adfg«7(�ry7wrc�
G3UII one:
fol' C%On�,rT�UeG?O^ CITY OF CUPERTINO-BUILDING DIVISION
C°atradm.Name: Lie.No: APPLICATION / PERMIT
BUILDINGELECTRICAGPLUMBING-MECI MCAL CATEGORY CONTROL«
ArcMted/Engineer. Llc.No:
.t/ �^ --// (� " QTY. ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..dtb�.2EnPtr �� / c .
[rERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRAu Fde,p DECLARATION
IhembyaffhSKtIo 700Bol iv Bcen3afthe erpresand Pr(Chapler ode and APPLIANCFSRESIDEMiAL JOB ON
Iogwftficar.h Section 7000)ofDWfirta. fthe BudnessandPro(eWonsCode,andm
LIcmalCI.. (�eand dfett. PANELS
License clam Z5 k.# 5_9'73/7Jrl6'�i`P�'�frC\
Date Contractor
ARCHITECTSDECLARATION 701-IMOAMPS
q�q�uu p Z I understand my plana shall be used as public records OVER 1 ODO AMPS SQ.FT.FLOOR AREA $/°.R.Fr.
E Licensed Professional SICNSELECTRLCAL ALE D
pOWNER-BUILDER DECLARATION
Gi SPECGLCE4CNT/MIST
Z t..,� Thereby a(Ortn lhatlam exemptfrom the Conlrador's License Law forthe QQ fallowing reason.(Section 70315,Business and Protractors Code:Any city or
Fs'ty county which requlresa perrnit tomrutruct,alter,improve,dennlish,or repair TFMP.METFRORI'OLE INST. M PiaYTEI
�
3< anystmMmpriartoitsL ame,aborequimtheappUmntforsuchper tto POWER DEVICES
rYG V Ole a signed statement that he b licensed pursuant to the provbWm of the
3u, nAn
Contractor's License Law(Chapmr9(commrrcirg with Stolon 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O Is
sloe 3 ofthe Business and Profemloru Code)orthat he b exempt therefromancl
�?o the haste(or the alleged exemption. Any violation of Section 7031.5 by any
GICCr57j OUTLETSSLCHF.S-FTURS as
applicant permit subjectsthe applicant to a civil penalty of not more than V
five hundred dollars($500). NEW RESIDENTIAL ELECTS SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages as their sok
compensation,wRl do the work and the structure is not Intended or offered for
Osale(Sec.7044,Business and Professions Code:The Contractors License Law
93 does nm apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES.UNITS
who does such work himself orthrough hisown employees,provided that such
improvements are not intended oroffered formle.If,however,lhebuilding or TOTAL:
Improvement bsold withinoneyearo(compleinntheowner-bullderwlll have
tlg�urcieo of proving that he did not build or improve for purposeo(sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mmd
ndthe pmO(Sec.7044,Business and Professions Code:
The Commc mrs License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts ALTER-DRAIN&VENT•for such pkolecta with a WATER(EM
cpRLfactor(a licensedpummntiothe Contndm's Limnw Law. FEE SUMMARY
LJ 1 am exempt under Sec B k P C for this mason BACK FLOW PROTECT.DEVICE
nllyqlnvvrrqOwner Date
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
WORKMAN COMP a7VSATION DECLARATION RECEIPT«
FECTURIES-PER TRAP SCHOOLTAX Y -N
certF11 hereby atfhm that 1 have certificate consent to pytmmm,ora RF-CE11vr«
l(IoteofWorkers Compensation Insurance ruunce o ce
rartlfbd mpylhereo((Sec. GAS EA.SYSTEM-1 WCAOUTLETS PARKFEE Y N
I'ol ry tlb C.)l0 7 Z3� RECEErI'X
GAS EA.SYSTEM-OVER 4(FA)
Co�any BUILDING DIVISION FRES
Cedl(ledcopybherebyththe city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Certified copy b filed withthe city Ivpedlan division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION ATIONINSURANCE SEWEILSANUARY-STORM F.A.200FT. Date Remi tM
(Ihbaectlon need red ctbe completed Elba permit b(prone hundrN dollars
($t 00edifess.)fythat In the performance of the worl�forwhich this permit Is Issued, WATERHEATERW/VENT/FLECTR ENERGYFEE Y N
[shall not employ any person In any manner n as to become cabled to the WATER SYSTEM/,TREATING
Workers'CompenaatWn Laws of Gllfornla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SO.Ff. Date RCCeI tM
Z O NOTICETO APPLICANT.U,after makingthb Certiioteof Exemption,yuu
Hshould become svblect to the Workers'Compemprevision.ation pvisions of the Labor TOTAL:
CC W Code,you must forthwith comply with such provisions m this permit shall be BU �••
IL j deemed revoked. '
d CONSTRUCTION LENDING AGENCY SEISMIC FEE l
I hereby affirm slut there b a construction lending agency for the perform- ELECTRIC FEE
M 0 an.ofthe workfor which this permit b Issued(Sec.3097,Civ.C.) TOTAL:
L) lender:Name PLUMBING FEE
U. r Iendee.Addnac QTY. MECHANICAL PERMIT FEE
O W 1crtlfy thatl have mad thbW date thattheabovelnformation MECHANICAL FEE
1 is correct.l agree to complywith all cityand county ordinance and state laws PERMIT ISSUANCE FEES PAID:
>• relating to building construction,and hereby authorize representatives of this
(— city to enter upon the above-mentioned property for inspection pu rposn. ALTERORADDTOMECH.
Z D
(We)agree to save,Indemnify an d keep harmhm the City of Cupertino ate Receiptit
L) against lbbillties,judgments,coetund caper.which may in aaywayaccme AIR HANDLING UNIT CTO 10,000 CPM) SUBTOTAL:
.Szh tsald Cl mnsequenc o e ,In thin permit AIR]iAND1INGLMT(OVER 10,000 CPM) CONSTRUCTION TAX
ruture pp n/ on dor �te a 1XHA115T1I00D(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous I IFATINGUMT(TOI0(%000BT11) Date ReCCi IN
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iiealth and Safety Code Stolon 25537(a)2 PLEATING UNIT(OVER 100,000 BTU) TOTA .
❑Yrs No
Will the applicant or future building occupant use equ 1pment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamloants as defined by the Bay Area Air
.
Quality Management District? BOILER-COMP OPII'GR 100,000 gill)Y. No # A
f V
haveroad thehar,Safer materials Semqulrer505, under Chapter G95°( BOILER-COMP(OVER 100,000 BTU)
the
erstadtatIfthroia &Ss(ety Code,not currently
5,25533
and 25534.1 DEC
y Pao understand that l(the building docs°cat currently haves tenanq thatltbmy NEWRISIDWITIALMETH. SQ.I•Trmpomflaility to notify the occupant of the requirements which must be metpdortoLasuanmofaCediticateofOccupancy. rs f II
Owner or authodred agent Date TOTAL:I
ISSUED BY:
OFFICE COPY