21582 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMHNO.
Building Address: ^/I /�n
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.era ams: one:
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1jJ CITY OF CUPERT[N0.BUILDING DIVISION
• Con adoraName: Lm.N.: APPLICATION /PERMIT /
064-rO BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE —BUIILLDING PERMIT INFO
Add.. PERMITIS5UANCE �,y ❑ ❑ F-1LICENSED CONTRACTOR'S DECLARATION LSI
I hereby affirm that l am licensed under prwblons of Chapter 9(commune. APPLIANCFSRF.SIDENTIAL JOB DESCRIPTION
ingwith Sed.n 7000)of DWlalon3ofthe Bu.inessand Prolesslons Code,and my
license Is in full to.and dfe# PANELS G
LicenseD-. '5' L.rhns 6sb9
nate/ri-3-Ja chneadnitr�n e4 ��/� � . eeP�71
ARCHITECT'S DECLARATION 20t")� �
T
q�q�vv Ore pz Iundenbnd myplaredhalbe used upubec records OVER 1000 AMPS ESQ.S.jI.�ARF�� S/SQ.FI'.
Licensed Professional SIGNSELECTRICAL L"MIN
LLT OWNER-BUILDER DECLARATION SPECIALCIRCNT/MLSC
z � I hereby affirm that l am exempt Prom the Contractor's License Law for the P UTE R
I
reason.(Sedton 7a315,Business and Professions Code:Any city or
Oz I—gd TEMP.METER OR POLE INST.
�� chuntywhich requlmapermlt tocors,Wd,alter,renprove,dennlbF,or repair r.�
anystm=mpdortoilsismance,alsomqulmlheappllantfweuchperrwtto POWER DEVICES DATE
�. file a signed statement that he is licensed pursuant to the provisions of the
3wt�, Cont.dor.License law(Chepter9(mmmencingwith Section 7D00)of Divi- SWIMMING TOOL ELECTRICt-•NOS slon3o(the Businessand Preimiom Code)orthathebexempttherefmmand VALUATION
4 the basis for the alleged exemption. Any violation of Section 7031.5 by any O 7LETSSW TCEIFSFU TURES p� QO
applicant for a permit subjects the applicant to a civil penalty of not morethan �Ja
fir and ed owner ars of
property,
NEW RESIDENTIAL ELPCTR SQFf. STORIES v) TYPECONSfRUCTION
7< I,as owner li the property,or my employees with wages r there door
.1.&c.alon,R.gretheworkand k,.0 dureh not.endedacsoe L offered for
O ole(Sec.apply
t uan owner
of property Co builds C improves L thereon,
Lw
S$ whoa not apply to an owner or property who builds hr Improves thereon,and OCC.CROUP RES UNITS
who
ovem ntsworkhimself edoruughhisownts.Ithemployees,
we providedthatouch
Improvements arc not Intended oroffered d(orale.If,however,the orwil.gve TOTAL:
Improvement b Bold within oecyearofcompldiory the owner-bu0der will have
ttie.kunden of proving that he did not build or lmpmve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contractors to construct the project(Sec.7064,Business and Professions,Code:
The Contacts'.Lt...law don nor apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
builds or Improved thereon,and who contactch s for sup(ojects with a
a�BtFaduals)licensed pursuant to the Contractors Llcense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L�I am exempt under Sec. B&P C for this reason
Owner S DRAINFLOOR,ROOF,AREA,COND. SAMTARY Y N Date RECEIPT N
WOR"AN COMPENSATION DECLARATION FI)(TURFS PER TRAP SCI TAX Y N
9Y7 ereby affirm that I have a lmuate of consent to pythwre,or RECEIPT
3800,mdlflabo(Worken'Compnuation lrs,urana ora certified ropythereo((&c. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3900,Isis C.)
PoI1gM - (wJL:fl/07 03 GAS EA.SYSW.OVER 4(EA) DINGRFKJCE0fN
Cam any 0/ N aJG4. BUILDING DI VISION FEES
�Certlled copy is hercbythMe city CREASE/INDUSML WASTE INTERCEPTOR PLANCHECKFEE
�eatified copy b(lied with the city Irs,pedlon division.
CERTIFICATE OF EKEM"ION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20011. Date Reeel IM
(1'hlesection need not be completed if Nthe permiSURA is!sone hundred dollars
(8t00)hrless.) WATER Ii EATER W/VENT/ELECTR ENERCYFEE Y N
I ce..t c at In the person
1 a of the work.as to b this permit eissued, —
I shall not employ any perwn In any manner n u to become wb)ect to the WATER SYSTEM/TREATING
Worken'Comprneation Lose of Califomla.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMR SQ.FL Date Recei tN
Z O NOlicant APPLICANT:If,after making this Certificate of Exhmpllon,you
Hshould become subject to the Workers'Chmpemat ton Provisions of the Labor TOTAL:
fD
Code,you=at forthwith comply w/hsuch provisinos or this perent.hall be
W > deemed revoked. BUILDING
CONSTRUCTION LENDING AGENCY SEISMIC FEE
ll I hereby affirm that there b a mwtrudlon lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is Lssund(Sec.3097,Civ.Q TOTAL:
U 0 Lender'.Name PLUMBING FEE
LLH Lndcr'sAadma QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
dW lartlfylhatl have read lob appliatloriand nate that the above Informal..
(1 brorred.Iagree t.complywith all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
7• N relating to building constructor,and hereby authorize representatives of this
F Z cit enter upon the abovementlor,M property fort pM.n purposes. ALTER OR ADDTO MECH.
agree to save,indemnify an d keep ha the City of Cupertino Date ReeeiptN
V o
ars llabllltl dgmenls res hmsyinanywayaccrus AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
n said In con c..f zrdl his permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature o(Appllant/Contractor tis EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei tp
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hc❑hhand Ssfdy Code,.Sedlo.255320)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' L
WIITthe applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazaidousalr contanneantsas defined by the gay Area Air gpa,FR-
Quality Management DisMd COMP pFm OR 100,0(D OTU) An®
4 Yn x711
have read the hazy Safety
Code,Sectors;
bundeand 25545.95 of BOILER-COMP(OVER 100,000 BTU)
the Callsni h. flath&Safety Code,Sedlone25y 75533 and 25534, 1 OCT l as�
undo a dthatlf the building doe.not mrrcntlyh ve a tenant that it b my NEW RESIDENTIAL MECH. SQ.FT. J 199
res I roily la Ify the pantof a nb which=at be met
P
! uanc aCe tc pan
�y coq,of Cuoert� ee,
Owners authorized agent Date ISSUED BY:�
TOTAL:
OFFICE COPY