19688 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ec Identification - PETRNTNO.
Building Addis: - 19688
C't..me; bU�R� Phone: CITY OF CUPERTWOBUILDINGDIVISION APPLICAITONSUBMIl A
L DAIV
c°m atlo aName Lic.No: APPLICATION I PERMIT 3—z— ^ /
BLULMNGELECTRICAI PLUECHA
MBING-MMCAL CATEGORY ' CONTROLN
rebitM/Engineer. Llc.No: -
'QT'Y ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: 'PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
,.I hereby affirm that am licenced under provisions of Chapter9(commeec APPLIANCES-RESIDENTIAL JOB DESCRIPTION
iless.I Sero f100)o( affect.
afthe BusinemandlarofeaeloneCode,and my
license le ie fu g'qqd c.11 PANELS
License Clam C..Cont c�
Dat CHIT or
ARCHITECTS DE RATION D0 AMP"'
NO pO ''I uddenPiero shall my Pieshall be used as OVER
public records. OVER 10D0 AMPg SQ.FT.FLOOR AR `5/SQ.FI.
Licensed Professional ` SIGNSE L rj
6 OWNER-BUILDER DECLARATION SPECIAL CIRC /
z � I hereby affirm that am exempt from the Contractors License Lawforth¢
OR. following reason.(Section 70115,Business and Professions Code:An tl or
r1I county which requires a permit to construct,alter,Improve,demolish,or repair TEMP.M � OR IN
g0 any structure prior to its issuance,also requires the applicant for such permit to c
E5 R file a signed statement that he is licensed pursuant to the provblov of the � R P
Q6 3 u, Contractoib License Lew(Chapter 9(mmmencing with Section 7000)of Divl-
�0� ston3 ofthe Business and Professions Code)orthet helsexempt there(romand NG LFI. C VALUATION
the baels(or[he alleged exemption. Any vlolatmn of Section 7031.5 by any a/ Q
0 applicant fora permit subjectsthe applicant to a civil penalty of not room than ETS 7CI SF[ �/l�l ��
five hundred ddba($500). NE ENITAL ECTR SQ.Ff. STORIES TYPE CONSTRUCTION
�n ML as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure isnot Intended or offered(or
q role(Sec.7044,Busbies...d Professions Code:The Contractors License Law
3� does not apply to an owner of property,wwhore
builds or improves Examen,and _ OCC.GROUP RES.UNITS
ice... who doessuchworkhimselforthruugh hisownemployees,provided thatsuch
improvementsarenOt tendedorof(eredforsale.](,howeveptbebulldingor - ,TOTAL: "
Improvement laeold withinoneyearofcompletW,theowner-budderwlll have . -
teburdenof proving that he did not build or improve for purpose ofsale.).. QTY, PLUMBING PE MIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE -
contact.to construct the project(Sec.7W4,Business and Profemlore Code: .. '
The Contracoes License Law dcee not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wtl
builds car improves thereon,and who comment for such Inples with a FEE SUMMARY
m,R[Ia&or(.)licensed pursuant to the Contractor's Llmnm Law. BACK FLOW PROTECT.DEVICE
LII am exempt under See. B k P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N -
Owner Data RECEIPT N .
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP - SCHOOL TAX Y_ N
ce
[it hereby affirm that I have certificate of com nsent er ,ora rti(Icate otWorkers'Compewtlonlraurance oracertifled ropypy thereof RECEIPT NGAS EA.SYSTEM-1 INCAOUTLETS- PARKFEE Y N
3800,Lab 7 s
RECEIPT If
Poliryp V GAS EA.SYSTEM-OVER
Com - BUILDING DIVISION FEES
[]Certifiedc pyls hercbyththe
[]Certified ropy ls(lied with the city ty impeclon division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF ElEMPTiON FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM PA 200F1' Date Remi t#
(Thissection need not W completed If the permit ls forone hundred dollen -
87170)orfyth roNWATER HEATER W/VENT/FLECTR ENERGY FEE' .Y N
• � ]certify that lls¢performance of (orwch this permit[¢issued,
I shall not employ any person In any manner sa as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawso(Callfomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQF. Date, Recel t#
Z O NOTICE TO APPLICANT:If,after making this Certlftraleof Exemption,you
should become subject to the Workers'Comper Bacon provlsions ofthe Lahor TOTAL:
CO Code,you=at forthwith comply with such pmvBtoro orthls permit shall beDUI BUILDING W 7 deemed revoked. .
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE $d
I hereby affirm that there let a comtrucion lending agency for the perform- ELECTRIC FEE
O ance of the work for whlchthls permit Is issued(Sce.M97,CIv.Cd ,TOTAL:
V Lender's NamePLUMBING FEE
F Lenders Address - QTY. MECHANICAL PERMIT FEE
OW, Icertltythatlhavereadthlsappllratimnand etatethatthe above information MECHANICAL FEE
6 lscorrect.I agree to complywlth all cityand county ordinances and elate laws PERMTTISSUANCE FEES PAID:
} N relating tobullding construction,and hereleyauthorize representativesofthls -
(— Z city to enter upontheaWve-mentioned property for Inspection purposes. ALTERORADDTOMECH. - Date ReCel t#
— (We)agree to save,Indemrdfy an d keep harntess the City of Cupertino
against liabilities,judgments,cosband expenses which may in anywayaccrue ' AIR HANDLING UNIT(T010,000 CF M) SUBTOTAL'
agat. City in consequence of Ae( an ng of this permit
n AIR HANDLING UMT(OVER 10,000 CM) CONSTRUCTION TAX
519 o App cant/Contract Date ' EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
• HAZARDOU 1ATERIALS DISCLOSURE - -
illtheapplicantorfuture building ocutpantamre or handle hazardous HEATING UNIT 100,000 BTU) Date R0001 t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the `
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) . TOTAL" 3 /E
F1Yes„ M No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) P1j1, NCE DA'Z'E .
which emit hazardous air contaminants as defined by the Bay Area Air E' -
.� Quality Managerrent District? BOILER-COMP OTB'OR 100,000 BTU)
vodthe
3usmaterials requlmmentsunder Chapter 6.95of BOILER-COMP(OVER100,000BTU) 7990
theClfemiaHealthkSafetyCmdeSectioa25505,75533and25534.
1 - -
understand that If the building does net currently have a tonanq that it ls my NEW RESIDENTIAL MECH. SFT. p�•����}��'
responsibility to notify the occupant of the requireme rds which must be root Ci J
to issuance o(a I(1 sof panty. �O .+IL7�-'Ll% ss_ ¢�
_
nerd aulhmized gent ate - �
TOTAL: ISSUEDBY:
OFFICE COPY
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