20099 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Prate d Identification - PERMIT NO.
Building Address: �� �r� D� 20099
caner. l_ one: A A
t33i-j H D CITY OF CUPERTINO-BUILDING DIVISION
• cn aunraNam: ue.Nm APPLICATION /PERMIT L4
I ' BUILDINGELFCTRICALML BINGMECIIANICAL CATEGORY CONTROL#
Architect/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: � TISSUANCE � ❑ MTr❑
LICENSED CONTRACTOR'S DECLARATION
Thereby cufflent that lam lkeneed underprovblonso'Coapt 9(commrnc- ANCESRESIDENTTAL JOB DESCRIPTION
Ingwlth&orlon 7000)of Dlvlelon3 ofthe Busl ncssand Proledo Code,and my
license lain cern .fico. ( P
License Chex is# L `ram
Date 7.Conmadcr DEC A 201-1000 AM p t'o Vn J�Ct Ffl
NaIun{dersttaand tLmyyy plans shall be used v public records. OVER1000 SQ.FF.FLOOR AREA S/SQ,FT.
NaLicensed Professional SIGNS ELECTRICAL
G�< OWNER-BUILDER DECLARATION SPE-CIALCIRCUIT/M15C
Ogg I hereby affirm that lam exempt from the Contradoes License law for the
Z Sdiowing maison.(Smion7031S,Businessand Professions Code:Any city or
s'u9 countywhlchrequl apermittocovtrud,alter,lmprove,demolbb,ormpair TE"P.METER OR POLE IN
g�IS 5a! anystrudurc prlorto its Issuance,also requlresthe applicant forsuch permit to
E5 O w V file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
f„ Contractor's License Law(Cha r9 commencin with Section 7000 ofDlvl-
%OI on 3 of the Business and Profession,Code).,that he is exemptthercfromand SWIMMING POOL ELECTRIC VALUATION
y.' the basis for the alleged exemption. Any violation of Sectio7031Z by any 0[TR,ETSSWITCIiESFIXTURES
applicant fora perretaubjectstheapplicantm.civil penaluyofnmt morctba.. oOv
c �e live I,as
nerofthepoa NEW RESIDENTIAL ELECTR SQ STOW TYPECONSTRUCTION
�I,as owner will
the properly,or he employees with wage. thele door
5t
compensation,Business work andProfescions,structurelaContractorot Intended or License Law
p d for
sale(Sec.apply to Business owner
of property
Code:Wids Contractors ereon law
�$$ doeanorssuch torn owner ofpropertywW Wlmorimproovided that such
e- whodonauchwork himxgorthrough hiaownemployoea,provided thatsuch OCC.GROUP RFS.UNITS
improvements are not Intended oroffered formic.If,however,thebuilding or TOTAL:
improvement is cold within oneyearofcompletion,the owner-builderwill have
th rdenof proving that he did not Wild or Improve for purpose o(sak3. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed
contractors to canstrud the project(See.7064,Business and Profesaiov Code: PERMIT ISSUANCE
The Contractor.License Law does nor apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) 4
Wilds or Improves thereon,and who contracts for such pkujecis with a
cgB[(ador(s)11¢nsed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE' FEE SUMMARY
nal am exempt under Sec. B&P C for this reason
DRAINS.FLOOR,R SANITARY Y_ N
Owner Date R, OOF,AREA,GOND. RFGmT#
WORKMAN COMPENSATION DECLARATION pg(.NRFS I'F.R TRAP SCHOOLTAX Y_ N_
❑1 hereby affirm that I have a certificate of covert if. re,ora ,-ro R_ N#
certificate ofW.rIers'CompevationI.nmm ora certiflearopy thereof(Sec. GAS FA.SYSIFM-1 INCAOUTLETS PARK FEE Y N
3800,Lab C.)
Policy# RECEIPT It
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy b hereby furnished.
eniBed copy b filed with the city inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF E%LT4ITION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Dale ReceI t#
(fhlsaedion need not 4 completed if the permit b forma,hundred dollar
OI�JOf1CWATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertily that in the perforrtunceof the work(orwhkhlob permit is bsuN,
I shag not employ any Person In any manner x as to became subject to the WATER SYSTEM/TREATING
Workeri Compensation laws of California.Date PAID
O Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ,FF. Date Recei t#
P: shoold become subject n,
to the Workers'Compeation provisions of the Labor TOTAL:
N
Code,you comply with such provisions or this permit shall be
CCU)
deemed revoked.
BUILDING '
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihecebyaffirm that here b a covuuctlan lendingagency far the perfornF ELECPRIC FEE
Z aem.f the work far which this permit is Issued(Sec.3097,Civ.C3 TOTAL:
U O larder's Nang PLUMBING FEE
Iy aer.nddren Q'Y. MECHANICAL PERMIT FEE MECHANICAL FEE
Q W I cartitythat l hzvereadth a tideand state thattheabove Information
1 Ism ct.I agreeto comply with all city and county ordinances and state laws&�HAusm
E FEES PAID:
} N relating to building construction,and hereby authorize rcpresentatives ofthb
I— Z city to enter upon theaWvcmenHoned property for Inspection purpose. MECH. Date Reeel t#
_ (We)agree to save,Indemnily an d keep harmless the City of Cupertino - P
against liabilities,pdgments,costuand expenses which may In anywayaccmeMT(TO10,000CFM) SUBTOTAL'
against said City in consequence of the granting of this permit.
NIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappil rd or future building occupant store or handle hazardom HEATING UNIT 100,000BTU) —Date Recei f# /—(s7
material as defined by the Cupertino Municipal Cade,Chapter 9AZ and the
Health and Safety Coda Scdion 75532(a)i HEATINGUNIT(OV 100,000BTU) TOTAL:
Ye No
Will the applicant uhim Wilding occupant use equipment or devices VENTILATION FAN(SIN ERESID) ISSUANCE DATE
which emit hazardo aircontaml.nuns,defined by the gay Area Air
Qu Iity Management d7 BOILER-COMPOHPOR100, BTU)
4Yea No
have read the hada ous rtuuedab require is undcrChap(er 6.95 of BOILEILCOMP(OVQ4100,0008
the Cailfornb Health&Safety Code, dlov ,75533 and 25536.1 1✓'
understand that
if
building don of curt yhave atenanL that itkmy NEW RESIDENRAL MECH. Fp -
respovibllgytonotifythe tof the Ircments wh lch at be met ��� v NEW priortoissuanc Ce me ofOdv 5 J
Ownerorau orf d t L Date
TOTAL:
OFFICE COPY