23711 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Bulldin'Add®a5 23711
nen ams: lune: _
J owl R E K ITT K E CITY OF CUPERTINO-BUILDING DIVISION r�'� Y
a Contractor's Name: Lk.No: APPLICATION / PERMIT �`L 0 Z
J OAJ E M AIRY Wn6rl BUfLDING-ELE TRICALPLUMBINGMECHAMCAL CATEGORY CONTROL If
Arcllted/Englncer. Lk.Na
rse�ss QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddMsw ODi/ O SM/JASG ;;d TISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcensed under provisions of Chapter9(correame, APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sedlon7000)of DiHMcn3ofthe Buelnenand ProlesslonsGode,and my
licLicense
In full Lbc,# n PANQS
Date Class .otr „� 35'l
Date Cantnctor
ARCHITECPS DECLARATION 2014000 AMPS
02 l understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
O.
Qg Lkensed Pmfesslavl SIGNSELECTRICAL
'`61- of OWNER-BUILDER DECLARATION
Z_rT 3 thereby affirm that I am exempt fromthe Contractors License law for the SPECIAL CIItCUIT/MISC
QQ following mason.(Section 7031.5,Business and Professions Code:Any city or
Ff' countywlklrequimsals,mdttocovtrud,alter,impmve,dennllsl,orrepalr TFMP'MEfL720R POLE INST.
qqq� anystrudure pdortolts isnrave,also requlreslhe applicant for such permit to
1 file a signed"(•meet that he is licensed pursuant to the provisions of the POWER DEVICES
O w Contradore License Law(Chapter 9(commencing with Section 7000)of Dlvi-
3 a swmilnNc POOL ELEcrwc
the hast for
ed Professions Code orlation f exempt therefrom and VALllAI-1fj�
6 the bean for the alleged exemption. Any t toladon of nattySectiono not room
by any OUTLETSSWITCHFSFIXTURES I Z'Sd �`�'–J_
appBnntfor a permit subjects the applkanttoactvll penalty of not rrorcthan �,f
five hundred dollars($50M.. NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
�n ❑1,as owner of the property,or my employee,with wages as their sole
compensation,will do the work and thestructure is not intended or offered for
q sale&c 7054 Business and Pmfeaskma Code:The Contractors Limme Law
docs not apply to an owner of property who builds or improve thereon,and - OCC.GROUP RES.UNITS
does such work himself or through Msown employees,provided that such
Improvements are not intended oroffered(weak.If,however,thebullding or TOTAL:
Improvement issold withinomyearofcomplelion,the owner-bullderwlll have
tlrvrelen of proving that he dm not bund or improve forpurpose of ob.). QTY PLUMBING PERMIT FEE
"L as owner of the property,am exclusively contracting with licensed Ft'OOD TONE APN
PERMIT ISSUANCE
contractors to construct the pmjed(Sec.704k Business and Profess lona Code: a
The Contndars License Law don nor apply to an owner of properly who ALTER-DRAIN VENT-WATER(EA)
Wild.or Improves thereon, and who contracts for such pko*u with a
cq➢t(acmeW licensed pursuant to the Comradoe.License Law. FEE SUMMARY
LJI am exempt under Sec. B Is P C for this reason BACKFLOW PROTECT.DEVICE
OUTSIDE FEES
ate
MDRAINS FLOOR ROOF,AREA,DOND. SANITARY Y_ N—
D
WORKMAN COMPENSATION DECLARATION RECEIVE 0
FIXTURES.PER TRAP SCHOOL TAX Y N
Owner
� hereby affirm that I have certificate of consent to spythmn,ora RECEIPT N
certlflaleof Workeri Compevatlonlnsuranceoracertllisd ropylhenro!(Sec. GAS,FA SYSI•FTII INCA OUTLETS PARK FEE Y N
3800,Lb CJ a / RECEIPT a
Policyp GAS EA.SYSHM-OVERHEq
Com BUILDING DIVISION FEES
MCedified copy is herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
�Cedified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM F.A.20OFI, Date Recd UI
IThlesection need not be ENSAI Ntie SURA is(orone hundred dollars
(4100)or less.) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I certify that In the perfonerammof the work forwhlch this permit to issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/IRGTING
Workers'Compensation laws of California. Date PAID
O Z Applicant Date Receipt#
Z O NOTICE TO APPLICANT.If,after making t his Certificate of Emcrptlon,you NEW RESIDENTIAL PLMB. SQFT.
should becomnmbject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,youmut forthwith comply witheuch provisions orthis permit shall be ^'
deemed revoked. LD •'
G F
LU
C . CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrrothat there is a construction lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sem 3097,Civ.C.) TOTAL:
V O (.ender'.Name PLUMBING FEE
LL ~ Lender's Addre.a QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdifythatllavereadthisappllrati...nd tatethattheaboveinformation
C iscorrect.I agree to comply with all city and muntyordlnanmand date laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and herebyauthmicerepresentativesofthis
I– U) city to enter upon the above-mcnlloned property for Inspection purposes. ALTER OR ADD TO MECH. Date RCCCI t>f
U _ (We)agree to save,Indemnify an d keep harmless the City of Cu ped Ino P
agalost liabilities,judgments,mats and expenses which may In anyway acme NR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
,gal t aid Chyin con uenceofthegrantingofthlspermlt.
5 20-9 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Brant/ tractor Date MIT IAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZA )OUS MATER IALS DISCLOSUR E '
Will the applicant or future building occupant store or handle havrdous HEATING UNIT(TO 100,ODO BTU)
material as defined by the Cupertino Mu niclpal Code,Chapter 9.1 2,and the DateRCceJ fp
Health and Safety Codr Srdlon 25532(x)7 HEATING UNIT(OVER 100,000 BTU) TOTA
0 Yes M No
Wllltheappllcant oFTuwmildingompantusecquipmentordevices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which eMt havrdous air connMants as defined by the Bay Area Air
Thy Mavgerrcnt Dlstrict7 BOMER-COMP(3HN OR 100,000 BTO)
Yes 4No p
lave read the havr oua
Isrequirements2555,2SS3 aChapter. 1 of BOILER-COMP(OVOtt00,000 BIlJ) pi
the California licallh ASafety Code, ID
Sections 75505,25533 and 755M. I
undrnland that lithe 6uliding docs not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT n `'
te
responsibility to notify the occupant of the requinnents which must be and nl {] Or
prior to issuance o(a Certificate of Occupancy. MA
Owncrorauth.mcdagmt Da 'ILL I
TOTAL: ISSUED BG –
OFFICE-COPY