24316 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PENONLY
Building Proled Identification PERMITNQ, 4316
Building.ZaB 4z .4 aG7
wners sore: .�Nr� one: . APPLICAM
/IP� G,a1,�=6� 6aw CITY OF CUPERTINO-BUILDING DIVISION
N
Contractor' ame: �� Gc.No: APPLICATION / PERMIT
GBUILDINGELECTRICAL-PLUMBINGMECI AMCAL CATEGORY CONTROL 8
A Itacl/En neer. Lic.No:
r
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCH ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
Scoria irmtlutlaivsolicensed 3oftheunder provisions offeadon Code,andm APPI]ANCESRESfDENTUL ]pgD ON
lcgwe.1.full 7.00)ofd died. the BuslneuandProlesMonaCode,end my
license le In full force and c,# PANELS
Date Cbss LILY
Date Con[nctor _L_ UPTO20DAMPS
ARCHITECTS DECLARATION 701-IODOAMPS
p�p�uu m0 7: 1 understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
5i Limned Professional - SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION
In} SPECIALCRtCU1T/MISC
owing reason.
that Contractor'sLienee Law to he
followingreaaequ( Ion7rrdtto utlneuand rimpm ns Code:Mytlty it TEMP,METER OR POLE INST.
0,4 countywhbh requlma boalattomnstmctiresth apmve,demolbb,ormit to
a any awdumpderm menty that he i,also censed mluant to tantforsurb isions of to POWER DEVICES
�K.�U file a signed statement that he b licensed pursuant to the provisions of the
36 meVALUA
Contractor's License Law(Chapter9(mmncing with Section 7000)of Divi- SWIMMING POOL ELECTRIC T
OJ sl..3.fthc Bu Ln....d ProfeulonsCods)orthal he b m
meptlherefrocrend O
OA the bub for the alleged exemption. Any violation of Section 70312 by any IU OUTLETSSWITCHESFLYFURFS 2 QM
appumnn
t fora permitsubjeslheapplicamtoadvll pensltyofnal morethan 7 W
�
five ndmd dollars( .C mow ner o(1M Property,or my empbyeu with wages u their sole NEW RLSIDENTfAL ELFGTR SQ.FI. STORIES TYPE CONSTRUCTION
7.a �naHon,wlllde the work,and thulmmare b not Intended or offend for
HO e(Set.7094,Box as
Professions Code:7he ConiratloJs Licerue law
HO does &apply to an owner of property who Wilde or Improves lhemoc,antl OCC.CROUP RIS.UNRS .
CW. whodoessuchworkhn if rth.ghhbownemploycee,pmvidedlhatsu<h
bnpro nrenbare not Intended oroffered forsale.Ifhoweveythe Wildingor 7
improvement bsold wllhinonsyearofcompletion,the owner-builderwlll have
11ELtZurden of proving that In,did cat Wild or Improve for purpose ofale.), QTY, PLUMBING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with limned FLOOD ZONE APN
mntracton to contract the project(Set.7014 Business and Profenlons Code: PERMITISSUANCR /
The Contractor's License law does not apply to an owner of property who AL IN&VEM-WATER(EA)
builds or improves thereon,and who contracts for such p(ojerts with a
cgR(r+dmW licensed pursuant to the Comrade.Lienee Law. ACK FLOW ECT.DEVICE FEE SUMMARY
LJI am exempt uMer Sec B&P c for this masonOUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,CONTI. SANITARY RECEIPT N
r WORKMAN COMPENSATION DECLARATION
[]1 hereby affirm that 1 have a ertlflale of consent to self-Insure,m a I>IX'IVRES'I'ER 77tAP SCHOOL TAX Y_ N_
RECEIVE
rtlflam of Workers'Compensation Insurance or a certified copy thereof(Sec.
ceM
3800,1ab C.) GAS F.A.SYSTEM.1 INCA OUTLETS PARKFEE Y_ N_
Policy N RFCEPTNGAS EA.SYSTEM-OVER 4(EA)Com___000any � BUILDING DIVISION FEES
I I Certified copy is hereby with
the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
LK1Ca Ifled copy isfiledwiththe city impaction division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA 200F1' Date Reed tri
(Thtssedion need net be completed If the permit bfm ons hundred dollars
(51fess.)
I mdtthat b WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
certify that the performance Issued,work for width this permit .ucd,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compenufion law.of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Recel tIll '
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provblons of the Labor TOTAL..—
Code,
OTAL:Code,you must fort hwlth comply with such provblons or this permit shall be G �r
7 deemed revoked.
BUIL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z . lherebyaffirmthat them baconstrudlonlending agency for the pedorm T ELECTRIC FEE (j
ante of the work for which this permit b Issued(Sec.3097,Clv.C.)
O I<nder'e Name - PLUMBING
.F Lender's Add reu QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certifythal l have mad thbapplleatlonand statethattheabove information
bcorred,I agree to complywith all city and county ordinances and Mate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this
city to enter upon the abovementiorud property for Inspection purposes. ALTER OR ADDTO MECH. Date Reeei IN
(We)ager to save,Indemnify an d keep harmless the City of Cu Fenton AIR HANDLING UNIT CFM)
aga Wt liabilities,/.tdgmenb,costs and expenses which may in any way accrue SUBTOTAL:
against void City in consequence of the granting of this permit.
AIR HANDLING IIN7'f(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data M(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcopant store or hand Is hazardous BEATING UNIT(TO 100,000 BTU) Date Recel tN
material a.defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU TOTA .
❑Yu No
WIIIIhezppliant or tum Wildingouupantuuequlpmentordevimv VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qu Iity Mangcment District? BOILER-COMP OHP OR 100,000 BTU)
❑Yea o No
Ihave read the hazardous materials requirements under Chapter 6.95 of BOMER-COMP(OVER 100,000 BTU) ®�
the Gldrnia Health&Safety Code,Sections 25505,25533 and 25534.I
- \ understand that if the building does nor currently have a tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT 19g�
responsibility to net mmo
ify the occupant of the requirement s which at be tract T �.� ly
prior to bsu ceof a Gerd to of ancy. Q
• ��—�9�, oC1 yluj
Ovnerorul age Dale TOTAL: ISSUEDBY:t
OFFICE COPY