23035 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proem Identification PERMITNO.
Building Address: , - - 23035
a 1W one:
CITY OF CUPERTI NO-BUILDING DIVISION s�
c°no- 4 APPLICATION / PERMIT
• Architect/G neer BUMDINGELECTWCALPLUMBING-MMHAMCAL CATEGORY CONTROL#
RI Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addres. 44V 1 61 PFRhITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION hereby
amst..3dunder provisions oufaso.er9(commm APPLIANCESRE9DEMlAL JOB DESCRIPTION
In aux.i.action 700(go(d affeon3 ofthe Buslneesand Pro(esslonsCode,and my
license le In fes dd(ect. PANELS
Lice Lic#
Dat CIFFIE r Tl nlr
ARCHITECTSDECLAR ION 201.1 00AMI'S
��ppvv 0 CQC I unden/and my,taro shill be used u public records. OVEROVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FC.
L'lyyy U Licensed Professional SIGNS ELECTRICAL
�GG<� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
1 herebyaffirm that am exempt form the Contractor's License Law for the
oo Q following reason.(Sectlan 703 S,Business and professions Code:My city or
Oz^' coon whkbrc Iresa permit tocomtru TEMP.METER OR POLE INST.
P� ty qu pe ct,alter,improve,demolish,orrepair
anystrucurc priorto Its issuance,also equlresthe applicant for such permitto rNG
filePOWER DEVICES a signed statement that he is licensed punuant to the provisions of the
30� Contractors Licerue Law(Chapter9(mmrrencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
don3 ofthe Businessand Prefrsslons Code)orthat be is exempt therem
froand VALUATION
P3< the basis for the alleged exemption. Any violation of Section 7071.5 by any OUTLETS-SWITCHES-FIXTURES
fora permit subject@ the applicant to a civil penalty of not merethxn
Ove hundred dollars 0N
(f5 . NEW RESIDENTIAL ELEC7R SQ,FI'. SR7WES TYPE CONSTRUCTION
���jjj �n ❑I,as owner of the property,or my employees with wag"as their sole
C compensallon,wllldothe work andthestructure is not Intended or offered for
'$ O ssle(Sec.7066,Business and Professssions Code:The Contrectr'.License Law '
does not apply to an owner of property who builds or improves thereon,and OCC.GROIII' RES IJNI75
m
whodo"such work himself or through his own employees,provided that such --
Improveentsarenot intended oroffered for sale.If,however,the building or - TOTAL;
Improvement issold within one yea rofcompletion,the owner-bullderwlll have
tl� rden of proving that he did net build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
u I,as owner of the property,am exclusively contracting with IlmnsN PERMIT ISSUANCE
contractors to pomtmct the project(Sec.70K Business and Professions,Code:
The Contractor'@ License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(Wbuilds or Improves thereon, and who contracts for such p�ojece,with a
�'qR�+dor(s)Ileensod punuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec, 0 k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N� -
Date RECEIPT Y
WORKMAN COMPENSATION DECLARATION FDcnAzPS PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o certificate of consent to op thereof(Sa RECEIPT#
certificate ofWC'L rken'Cwmperuatlonlmunnm ora certified copy thereof(Sec. GAS EA.SYSTEM-1 INCE OUTLETS PARK FEE V N
3800.Lab C.1 -♦P 114 —1 - RECEIPT#
I'o11ry M�� GAS EA.SYSTEM-0VER 6 BUILDING DI VISION FEES
Com anv���s h 1�-imed. �� (�)
ertlfied copy b heed with the
cid. GREASR/INDUSTRL WASE INTERCEPTOR PLANCHECK FEE
Certified mpyb(iled with the city Wpectlon dlvl6lon.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASEIIUP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200PT Date Recei t#
(This section need no[be completed If the permit V forora hundred dollen
(8100)orless) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
[certify that lnthe person in
the
nnersfor
as to
bco pemNHslssued,tothe —
1 shall not employ any,Lawn In any manner sw"to become subject to the WATER SYSTEM/TREATING
WorkLri Cwmpemauon Laws of GOrwrnla.Data � PAID
0 Z Applirent NEW RESIDENTIAL PLMB. SQFT. Dale Recei t#
Z o NOTICETO APPLICANT.If,after makingtho Certaate of Exemptlwn,you
should become sub)Lct to the Workers'
Compensation provlalwra of the Labor TOTAL:
CC W Code,you at forthwith compsuch provlsora or t
ly with h lhis permit a hall be
W > d"med invoked. BUILDING FEE
a C1CONSTRUCTION LENDING AGENCY SEISMIC FEE
7 Z
I hereby affirm that then is a construction lending agency for the perform- ELECTRIC FEE
ante of the work for which this permit is issued(Ser.3097,Clv.C) TOTAL:
(,) O Lender.Nacre PLUMBING FEE
LL F- Lenders Addre" QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW . Imdilythat l have read thisapplicalionand statethat theabove Information
IL iscorred.I agreeto comply with allcityand countyordinancesand date laws PERMIT ISSUANCE' FEE$PAID:
>. relating to building rovtruciien,and hereby authorlurep—nta0ves°!this
Zcity to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date RC[ei t#
V (We)agree to save,Indemnify an d keep harmless the City of Cupertino - P
against liabNlies,jrdgmarts,consand expenses which may In anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ag Is,city In conseque he rami sub molt AIR HANDLING UNIT(OVER 10,00M70CICONSTRUCTION TAX
44
'1 ns, re of Applicant/Contractor EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATEkA. DISCLOSURE
Will the applicant orf lion'
buildlegoccupant@tore°rnandishazardou. HEATING UNIT(TO 100,000 BTU) Date Receipt#
materialasdeMed by the Cupertino Municipal Code,Chapter 9.12,and the gm
-
I lealth and Safety Code Section M32(a)? HEATING UNIT(OVER 10,0110 BTU) .TOTA
qYe@ rjNo
llltheapp0ant orfutumbuildingoccupantusacquipmenl°rdevlc" VNITILATIONPAN(SINGLERESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Alr
Quality Management District? BOILER-COMPOHPOR100,0WEITU) , ;PAID P p ' D
4 Yes No IY
have readthe hac. esus matenabrequlrementsunderChapter6.95of MOILER.COMP(OVER 100,000 BTU)
the California Health&Safety CuuIc Secttom 25505,2SS33 and 25536, I D Q
understand that lithe building does not currently have.tenant,that it is my NEW RF_9IDENTIALMECH. SQ.Ff F�B (d�V '1992
responsibility to notify the occupant of the requirements which most be met
pri t once.1'a CLrtffica nry.
c rauthorlud agent Sill uUmnlilly
Dae
TOTAL: ISSUED OY:
OFFICE,COPY