23685 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PMWT NO.
Building Adds _resI Front-.s: 2 3 6 8 5
�wtgr3 C � s-Fo rGl_,�1 rive.
l k 1 - -([>✓ ZS —L� L{ ICITY OF CUPERTINO-BUILDING DIVISION f1 r �-
- f-
Conm ;Name: Lie.No: APPLICATION /PERMIT
3�[o3S BUILDINGELFLTRICAL�PLUMBING-MMC MCAL CATEGORY CONTROLM
Architect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PFRMITISSUANCE � 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
b affirm'hat lam underpovblonsofC ,anenc MPANCESREADENfIAl JOB DESCR0N
ingwithctt..7000)o(DlvlM.3.flheB.Mnessand Pettiest
...Codeed
my
licon.isCInssf! effect' / JS PANELS
LICM // • 1L�
V Com'
Dale Cordractor
ARCHITECTS DECLARATION Gl�nf 201-1000 AMPS
re0]. I understand my plan sMR be used as public records. OVER]ODD AMPS SQ.FI.FLOOR AREA S/SQ.Fr.
O
Licensed Professional SIGNSELECTRICALFIN
'
<� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MIST
7f' � fherebyafittemfrom the lam exempt frothe Contractor.License law for the
following reason.Section 9031,5,Business and Professions Code:My city or R�
O countywhichrequ4 apermittommu cu alter,impmvgde=tah,orrepalr T�P.METER ORPOLE INST. .Era�l(
Fq��a anyse ]OWER DEVICES ucture prior to its Issuance,also requiresthe applicant form hperMtto
li Mi 2 U file a signed statement that M Is licensed pursuant to the provisions of the 9 �2
Ow Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi- SWEdbfING POOL ELECTRIC
the taxis fo Busmnsand Professions Code)Iodati n of exempt therefrom and VA ATIOIy_
,pJ yy�.'•-t
the basb for the alleged exemption.on. Any violation o!Section nor ex re any
Wpbs fiveapplicantdred fora permit
a.($50jectn theapp0cant toa dull penalty dnot nnrethan OUTLETSSWITCHESFIXT[RFS L O
ee
five hundred as owner
riof the pro NEW RESIDENTIAL ELECTR
❑ease ownerll theproperty,orand he employees inwithwage as their sole �'�' M � TYPE CONSTRUCTION
tampensatlon,Businetheworkfeval et Code:
mh C Intended oioffendfor
5 � sale(Sec.704y Business andl'rofesslom Code:TM Contractors Licewe law
[tjG$ don not apply to an ownerof property who builds orimprovestlerme,and OCC.GROUP RFS.UNITS
44S whodon w
suchworkhmeelforthtgh hlsownemployces,providedthatsuch
Improvements are not Intended proffered forsale.IL however thebuilding or TOTAL:
improvement bsold withmoneyearofcompletion theowner-bullderwill have
thElIntrden of proving that he did nor build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed
contrarian to construct the project(Sec 7074,Business and Prdessbra Code: PERMIT ISSUANCE
The Contractors License Taw does nor apply to an owner of property who ALTER-DRAW&VENT-WATER(EA)
Wilds or improve thereon,and who contracts for such p(ujects with a
m dorG)Bmnsed punmmmthe Cpntnctor's License Law. FEE SUMMARY
LJ I am exempt under Sec. 8&P C for this myon BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT It
WORK MAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOLTA Y_ N_
❑I hereby affirm that I have o Insurance
a c of consent to opy thereof
ora RFC®xT N
3800,ab of Workers Comperwtion Insurance ora certifkd ropy thereo(ISec.
3800,Tab C.) CAS EA.SYSTEM-1 WC.40I1TLET5 PARK FFR Y_ N
Policyk Z.1 RECEIPT M
GAS EA.SYSTEM-OVER 4(EA)
Co�any copyIPCI!/1 ��L.�6� BUILDING DIVISIONFEES
Cert! a copy be filed hereby
the city tra= i GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
EGef11fIM copy V Ned with IM city inspection division.
CERTIFICATE OF E(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
SEWFRSANITARYSTORM EA 200F1' Date Reeef t#
(Thissedlpn need not be compacted iltM permit Is forone hundred dollars
(8100)orl
Imrti(yththat in the performance o(the work(or which this permit is Issued, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
1 shall not employ any perave in any manner so as to become subject to the WATER SYSTEM/TREATING
Wmlve s Compensation Laws of California. Date PAID
O Applicant
Z NOTICE TO APPLICANT:If,after reeking this Certificate of Exemption,you NERESIDENTIAL PLMB. SQ-FT. Date Recei t#
z mN'
Fshould become subject to the Workers Compereatlon pro lsioro ofthe Labor TOTAL:
N Code,you most forthwith comply with such provisions or thin permit shall be
deemed revoked. BUILDING FEE
W p CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il I hereby afflrmthat there is a comtructlon lending agency for the perform. ELECTRIC FEE
Z anceoftheworkforwhlchthIsperrnit Islu (Sec.3097,CIv.C.) TOTAL:
O O Lender.Name PLUMBING FEE
LL ~ Lender§Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iurtifytha l have read thls appliationand state thatthe above information
u tarrect.I agreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} 00. relating to building conswdket,and hereby authorize representatives of this
F Z city to enter upon the abovnmentloned property for inspection pu rposes. ALTFRORADDTOMIECH.
(We)agree to save,indemnify an It Imp harmless the City of Coped Ino Date Reeeipt#
V agaimtllab111tln,judgurentn,cossand expense hich nay In anywayaccuue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
a a' told City Nro ence of the grand. of this unit
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
core of Appli nt/Contractor Date IAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
ATARDOUS MA RIALS DISCI&URE
Will the applicant orfuturc building occupant store or handle hazardous HEATING UNTT(TO IOf1,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)2 HEATING UNTT(OVER 100,000 BTU) TOT
❑Yes M No
Wilitheappliant or suture Wilding occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hav Nous ab contaminants as defined by the Bay Area Air /y
Quality Management Distrid7 BORER-COMP Oil?OR 100,000 BTU) 1�
4Yn n No
havemad the baza�ous materials qulremnbunder Chapter 6.95o! BO ER-COMPOVLRID,000BTV) �AY1
the Ca llfcmia health&SafetyCode,Sections 25505,2W3 and 25534. I ��
understand that tithe building don not cormotly have a tenant,that it is my N'EWRMDENTIALMECIi. SQ,� (I,2
responsibility to notify the occupant of the requircerents which most be and C�l.r V♦ v7
prior to Issuance of a Certificate of Occopancy. N LUrt
Owner or authodmd agent Date ISSUED BY �• / l
TOTAL:
OFFICE COPY