23262 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
B.Ildi.x Pm en Identification PFRh9TNO.
Bulld7140 mit 23262
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ShVLe g(,( (/ —g3 Z CITY OF CUPERTINOBUILDING DIVISION
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APPLICATION I PERMIT
Name: k
1 Lv BUILDINGELECTRICALI'LIIMBINGMECHAMCAL CATEGORY CONTROLY
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. I PERMTISS'UANCEVIE ❑ INZ ❑ �1
LICENSED CONTRACTOR'S DECLARATION Lin VPI
Ihereby affirmthat l am licensed under prwisions of Chapter9(commenc APPWANCES,RESIDENTIAL JOB DESCRIPTION
ingwilh5ech )ef DlvWon3oft uY d (eaYonaCade,and my
Ilanx le loss o_ d(cct--1� PANELS
Llonnse Clan ICY
Date Conindor UP TO 2DO AMPS
201IODOAMPS
CHITECTS C TION
Q O I undemmWru�d my peMll be used u public records. OVER]000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
E o�j Licensed Professional SIGNSELECTRICAL
4 OWNER-BUILDER DECLARATION SPECIALCItCUIT/MISC
7f1herebyafHrm that Ism exempt fmmthe Contractors License Law for the
following reason.(Section 700IS,Business and Professions Code:My city or
O f.E TEMP.METIER OR POLE]NST.
� county which requires, mmm
apedtruR improve,tru ,alter,improve, or repair
'
qqq'y� any structure prior to Its Lnuame,also requires the appBonnt for such permit to POWER DEVICES
rlv, ilk a signed statement that he is licensed pursuant to the proxlsiora of the
Contractors License law(Cha er9(mmmencin with Section 7000)of Divi- VALUATION
31''In Pl B SWPTMING POOL ELECTRIC
elon3olthe Business and PmtemlomCode)orthat heIs exmptthere(comand
the basis for the alleged exemption. Any violation of Section 7MI,S by any OUTLEISSWITCHE FIXTURES
O eppbmntforapert tsubjectstheappllcanttoacivilperaltyufnm"mita(
R five hundred dollars(5500. NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure Is not intended or offered for
O sale(5cc.7W4,Busirass and Professions Code:The Contractors Llonme Law
does not apply to ss owner of property who builds or improves thereon,and OCC.GROUP R6.UNITS
deessuch work himself or through his own employees,provided that such
Impmvemenmare not Intended oroftered for sale.If,however,thebulldtng or _ TO
Improvement[ soldwithinomyearofcompidioNtheo em buRderwlllhave
tt,L�urden of proving that he did not Wild or Improve for purpose ofuleJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u 1,as owner of the property,am exclusively contra mg with IlmnsM pp m ISSUANCE
contractors to construct the pmject(Sec.7011,BusInessami Professions Code:
The Contractor's License law does not apply to an owner of property who ALI7R-DRAIN&VIMWATER(FA)
Wilds or impmvn thereon,and who contracts for such ptu)ects with• - FEE SUMMARY
ryWT+d 0)Bonnaed psarcasm to the C.m.doe.License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reasonOUTSIDE FEES
Owner Data re DRNNSFLOOR ROOF,AAG,COND. SANITARY Y_ N_
WOR COMPENSATION DECLARATION RFL�'f Y
FIXTURES PER TRAP SCHOOLTAX Y N
1 hereby affirm that I have a artifkate of consent to eel4lnm or RECEIPT Y
380D,Late o(WJLrkers'CryppYr�e�tlon lrcwunce or a certified copy thereof(See. GAS P.A. YSTEM-I INC OUTLETS PARKFEE Y N
polis Isis CJ/1/J.///�!�/ RECEIPT N
CroTr `V'""�� GAS EA.SYSTEM-0OVER
Co�m nv BUILDING DIVISION FEES
u` led copyb arebyfiled
the city GREASE/NDUSTR,WASTE INTERCEPTOR PLANCHECK FEE
ertl led copy is(lard with the city inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' CRF-ASETRAP PAID
COMPENSATION INSURANCESETVER-SAM.IEARY-STORM EA700P1• Date Remi t#
(Thlaxction need net becompleted tithe permit Isforone hundr d dollars
(S100)orless.) WATER HEATER W/VENT/ELICTR ENERGYFEE Y N
I certify that In the performance of the work for which this permit is Issued,
I shall not employ any person in any manner x u to become subject to the WA.Ni SYSTEM/TREATING
Worken'Compenution Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL ELMS. SQ.FP. Dale Recef til
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the WorkerCompensation pruvbloro of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions or this permit shall be BUILDING
FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL a e (the aorkfor tthercmaannit6 ord(ding agency 7,Civ. .) perform TOTAL: ELECTRIC FEE sn�
0 arm of the work forwhich thin permit IsLsaued(Sec.3097,CIv.CJ
Isoder's Name PLUMBING FEE
U. F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U 1certlfythatl havereadthis application and statethatlheabove Information X�771i
O W is correct.l agree to comply with all city and county ordinances and Yate laws PERMIT ISSUANCE aPU FEES PAID: -
} 1 relating to building construction,and hereby euthorlre repmxntatives of this
~ W cit to snteru est abovcmentlomd forW Ion s ALTER OR AUDIO MECH.
? y(WeI.gree to ,Ind fy a(d kkeep Men the ity of Cupertino Date Recei tic
V agalrmlmbi1, ,co. s;:rd expe(seswhichmayln anywayaccme AIR HANDLING UNI CIO 10,000 CFM) SUBTOTAL:
.g.out said Ci i o non of the ant this permit CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CIM)
SlgnaturecfA I / mramor Dam EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occupant store or hand Is hazardous HEATING UNIT(TO IM,000 HIM Date ReCCI IN
material as deOruM by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and SafetyCode Section 25537(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL. O—
as
❑YM No
WIIl the applicant orfutun building occupant on equipment or devices VENTILATION FAN(SINGLE REST IS§UANCE DATE
which emit hazardous air comaminanm as defined by the Bay Area Air
Quality Management District? ` BOILER-COMP 0HP OR 100,000 BTI!) M1
4Yea ❑No TJ a�
havemadthehazardousmalariatsrequirementsunderChapter6.95of BOILFR-COMP(OVEZ100,000BTU) A '
the Glifomla Health&SafetyCode,Sections 75505,25533 and 25531. 1 'JUL
understand that lithe building does not currently have a tenant,that It Is my NEW RMSD=AL MECH. SQ.FT.esponsibility to notify the occupant of the requirements which must be met v�I(a l
prior to Issuance of a Certificate of Occupancy.
CITY c
\ Owner or authorized agent - Date ISSUEDBY:
TOTAL:
OFFICE COPY