24406 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BujBuilding Address:lldln Pmcr'demHlcatl � ve Q�pe�i - PF7tMITNO,Z4406
nen am: lUZ ' one: - SUBMITTAL
CITY OF CUPERTINO-BUILDING DIVISION ^ C'
C°^endOlaName: _ ue.N APPLICATION /PERMIT / [s
B1IILDING-ELBCTRICAL-PLUMBING-MFf_HAMCAL CA RY CONTROL M
Architect/E,gimer. Lic, o.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:PjO — S P PERMITISUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthat l are licensed under provisions of Chapter 9(oommenc. APPLIANCESRESIDENTIAL JOB DESCRI'TION
ingwilh Seat1on7000)ofDiW9.3o(the Buslnessand ProfesNomCode,aod my / �/�•
licenseis InfuBf and diedic.#'��yS� PANELS tC l � 9 V a-7
LicenseOt= LICK 111 V
Date Contractor T 2011000 AMPS
UP TO 2DOANTS
ARCHITECTSDECLARATION
Q�u aO Zp ]understand my plain ahaB be used vpublic records. OVER 1000 AMIPS / rf(N•'fpaPDR jR� -g/SQ.FT.
E d Licensed Professional SIGNS ELECTRICAL Llppp�_p 1'Vg rI
GGGG 6 OWNER-BUILDER DECLARATION YI P q II T E R
IJn� SPECIALCB6CUIT/MLSC V LLL,���
p, owing r act n.(Sect l amexempt(romthe d Professim icanse,mince LawAny for the
F�.. following permit w estrum and Pimprove, Code:Mycityor TEMP METER OR POLE INST.
1" ceuntywhich requlrnaperrtdttommlmcL alter,improve,demol4h,orrepalr v
i nystmd mpriortoift Wuamc aL°requimatheappUmntfineuchperMtto POWER DEVICES AT
to - file a signed statement that he it licensed pursuant to the provisions of the
Conlnetor's License Law(Chapter 9(commencing with Section 7000)of Divi-
BOJ Non 3 of the Business and Professions,Code)orthat he V SWIMMING POOL ELECTRIC exempt therefrom and r•� VALUATION OO
the bask for the alleged exemption. Any violation of Section 7011.$by any OUTLETSSWITCHESFlXTURES D
O appBcantfora permltsubjecistheapplicanttoacivll pemityofn°troorethan JJ S D
$ five hundred dollars($5M. NEWRESIDENTIALELECTRFT.
❑1,as owner of the property,or my employees with wages as their sale STORE LN TYPE CONSTRUCTION
compereation,will do the work and the strvdure it not Intended or offered for
psa1e(Sm.7064,Businessand Professions,Code:The ContranoYa Llmme Law
( $$ does not apply to an Owner of property who builds or improves thereon,and CICC.GROIIP RES.UNITS
5; who does such work himself.,thr°ugh Nsown employces,provided that such
Improvements are nut Intended proffered forole.If,however thebuilding ue TOTAL:
1mpmvementbsaldwithinomyearofmmplelb theowner-bu0derwlllhave
t)Et¢uden of provingthat he did rant build or Improve for purpose ofol°.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
"4 as Owner of the property,am exclusively contracting with licensed
contractors to construct the projectt(Sec-7066,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who
Wild. ALTER-DRAIN AVENT-WATER MA)
or Improv.thereon, contracts ch theren,and who contfor supeo)ects with a FEE SUMMARY
cgB�don(s)Remand pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE
U I am exempt under Sec B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,OOND. SANITARY RECFIIT N
• WORKMAN COMPENSATION DECLARATION
0m 1 hereby affirthat I have a certificate of consent to self-Insure,or FD(TT]NFS PER TRAP SCHOOL TAX Y RECEIPT N NN
certificate o(Workersw
'CompeHon Insurance or a certiied ce
copy thereof(S . CAS F.A.SYSTEM-1 ING40[TILE(S PARKFEE Y N
3800,Lab C.) RECEIPT N
Policy p
Com any GAS FA.SY577MAVFR4(FA) BUILDING DIVISION FEES
ECedtfied copy is hereby furnished. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy k filed with the city inspection dlvlslon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20IFT Date Recel t#
(Chia section need not be completed Bthe perm0 bforom hundred dollars
(S100)teless.) WATER F{FA77R W/VENT/m cr.I.R ENERGY FEE Y_ N_
I unity that In the p rveo oft ework4 he file pertNtll cued,
I shall notemploya a d a mann o eco, to the WATER SYSI.EM/•TREATING
Workentcmpen o I I at PAID
1 O Z Applicant NEW RE9DENTIAL PLMB. SQFf. Date Recef t#
a D NOTICETO LICANT:ILa per kin'( b rtl( Ot Exemptiogyou
should become subject to the Workers'Campemt vislomofthe Labor TOTAL:
N Cade,you moat forthwith comply with suchprovlab ar this pemdt shallbe BUILDING -�
W 7 deemed revoked,
CONSTRUCTION LENDING AGENCY SEISMIC FEE
S Ihereby afflunthat there be mmtmction lending agency forthe perform ELECTRIC FEE
7 Z an ce oftheworkforwhichthbpert bees MTn.3097,Clv.C.) TOTAL:
52 Lender's Name PLUMBINGFEE
H Under's Address QTY. MECHANICAL PERMIT FEE
O W bmIcertifythat l have readthbapplicatlonovelnforrtutl°
andsntethattheab ^ MECHANICAL FEE
CL med.Iagree tocomply with all city and county ordinances and Yate Iowa PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize representatives ofth)s
cit to entero upon ve-me done pro
fe'rlm len ALTER OR ADD TO MECH.
Z y pO per')' PM p"rp0°G°' Date Receipt#
(We)agree to ,Inde fy d kee harmless the City of Cupertino
V -BeWtllabNtle d and nseswhlchmayinanywayamme AIRHANDLINGUMT(TO10,000CFM) SUBTOTAL:
against said a of a got pemnit CONSTRUCTION TAX.
NR HANDLING UNIT(OVER 10,000CFhf)
Sigodf reof Appgcant/Contractor Ekri EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building arvpant store or handle hassrdous HEATING UNIT HO 100,000 BTU) Date Reeel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Healthand Safety Code Spins 25532007 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑
Y. No
Willtheappliox or rebuilding arvpantuo equipment or devious VFNRl.AT10N FAN 6INGLE RFS(D)
which eISSU�AN EDITEcroft harardous air contarnrents as defined by the Bay Area A4
• Quality Management Dist 2 BOILER-COMP OHPDR 100,000 BTU)
Yes No
Ihave read the haxa auamaterlabrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) 28 1992
the California Health k SafetyCode,SMW.25505,25533 and 25536. I OCT
undentandtluti( he Nildingdon mmrrently veatenanLthatltboy NEW RESIDENTIAL MECH. SQ.FT
respomibilily t the p aft reqs, which must be met
prior to be. rat f a 0111 or VUY CRI 1110
ora d en Date
TOTAL;
OFFICE COPY