23963 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification I PERMITNO.
Banding Address:
23963
is K ��Ij (voap
wners ,me: ane: W1111LICA IION SUBMI I I AL I= -
d/ CITY OF CUPERTINO-BUILDING DIVISION ,�1
Cmaactorallo.- Lie•Na� APPLICATION I PERMIT
�E/NVQ Rcso >QSoN 0y a5 U30 7 Z BUILDING-ELF-CnUCALMUMBINGMECHAMCAL CATEGORY CONTROLp
Archltetl/Engineer. Lie.No:
n QTY ELECTRIC PERM11 IT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE �Jf ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L�
I hereection 70thatlamlken3ofthe ofChapter9 d,.m dmc- APPLIANCFSRESIDENTIAL OB�E�CR�jON
Incense I.etlion 7000)ofd effect.
on3o(theBusinessand ProreealonsCodc,and my '�
license le In full o dna erred. PANELS tri
LlceneeC ss W- Lk.« -
Dale'7 fontatlar
ARCHITECIFSDECLAR TION 201-1000 AMPS
O - I understand my plane shall be used as public memo& OVER 1000 AMPS SQ._ .FLOOR AREA - $/SQ.FT.
Fi I� Licensed Professional - SIGNS ELECTRICAL' ' w'
<6 OWNER-BUILDER DECLARATION E ® 'V
I"n] SPECIALCIRCUIT/M15C'
2F, Ihereby affirm that lam exempt from the Contractors License law for the
op following reason.(Sealon70)15,Businessand Profxedoms Code Any city or B �
E R
OZt. TEMP.METER ORPOLE INSf. XiMA P U
P� rountywhkh rcqubror
esa permit tosstrocl,siren m
Improve,deoWM1,or repair ��
g 'any s,tmaurc pdortolle lswance,aiw rcqulreethe appBantfa ouch pertmt to POWER DEVICES `7
[Sd Ole a signed statement that he is licensed pursuant to the provisions,of the /
3a, Contreaor'e License Law(Chapter 9(commencing with&orlon 7000).(Divi. gWQ4hgNC POOL ELECTRIC VALUATION
OJ elon3orthe Buslnmsand Professlmu Code)orthathelr,emmpttherefmmand - `
•] the basis for the alleged exemption. Any violation of Section 70315.by any OUTLETSSWITCHEhFIXTURES "1/1/S
« applicant into permit em
objecothe applicant too civil penalty of not ore than PPPttV//l/
w five hundred dollars($500). NEWRESIDENTIALELECTR
❑ SQ1T, SIONIFS TYPECONSTRUCTION
I,as owner of the property,or my employees wages as,their sole
t rompensatlon,wllldothework andthestmoture lenalntendedor offered for -
5 O sale(Sec.7044.Business and Profoealoru Code:The Contractors License Low
does not apply to an owner of property who builds or Improver,the.,and OCC.GROUP RES.UNITS
who doas,uch work himself orthrough his own employees,provided that such
Improvemems,are nm intended oroflered forazk.If,however,the building or TOTAL: ,
Improvement is sold within one yearofccompletion,the owner-bullderwill have _
t(r(„kurcien of proving that he did not build or Improve for purpose ofsale.). QTy. PLUMBING PERMIT FEE - FLOOD IDNR APN
Lf 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE�'.
contractors to construct the project(Sec.7044,Business and Professioru Code:
The Contacts',License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
builds or Improves thereon, and who contacts for such p(o)ects with a - FEE SUMMARY
ft ctorec.(e)Iimnsedpunuanttothe Cwn does Lkenw Law. BACK FLOW PROTECT.DEVICE
LJ f am exempt under SB k P C for this reason
OUTSIDE FEES
Owner - DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N—
. Date - RECEIPT' _ N
WORKMAN COMPENSATION DECLARATION TV(il1RF.S TRAPPER TRSCHOOLTAX Y N_
❑I hereby affirm that I have a certiBate of consent to copy
ora
aRECEIPT«
rtl0ate of Workers'Comperuonces
atllruuranacertifled coppy ththereore.f(Sec.
3800, CAS EA.SYSIFM-1 P1CIOl1TLEI5 , PARK FEE Y_ N_
Po11ryN I«
GAS FA.SYSTI3N-OVER4(FAI
Com an
BUILDINGDING DIVISION VISION EELS
Certified ropy is hereby furnished.
❑Certified copy V filed with the city inspection division. CREASE/LNDUSTRL WASTE INTF74CFPMR PLANCHECK FEE
CERTIFICATE OF IXEMPT[ON FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER�SANIpARY-STORM EA 200FI Date Recei t#
RFlsaetlion need not M completed If the permit b(Drone hundred dollars
($100).rle M.) - WATER HEATER w/veNr/ELecTR ENERGY FEE Y N
I cerulythat in the performance.(the work(.,which lhie permit la issued,
I.ball not employ any person in any manner so ore to become subject to the Wpm SYSTEM/TREATING
Wmken'CompensstionI woof Calilomb
O = Applicant NEWRESIDENTIAL PLMB._SQ.T. Date Recei [#
Z NOTICETO APPLICANT-.If,after making thisCertificate of Exemption,you
should become subject to the Workers'C.mpemxtion provielmu of the Labor TOTAL:
W Code,you must forthwith comply withsuch provisions or this permits hall be NG Moo"
> deemed revoked.
d O CONSTRUCTION LENDING AGENCY .'. SEISMIC FEE
I hereby.ffirm that there is a com uctlon lending agency forthe perform ELECTRIC FEE
Z ante of the work for which this permit b issued(Sec.3097,Civ.C.) TOTAL:
V O Lender.Name -- PLUMBING FEE
Iy F lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I anifythatl have read this epplicationand statelhatthe above Information -
a isrorrect.I egreeto comply with all city and countyordinances,and state laws PERMIT ISSUANCE FEES PAID:
>. relating to building construction,and hereby authotlae representatives of this
U) city to enter upon the above-menHmred property for inspection purposes. ALTERORADDTOMECH. Date' ReCel t#
V — (We)agree to save,indemnl ly an d kharmless the harmlethe City of Cu pertlno
agaostllablllifes,judgmentacortsandexpeneeewhkhmayinanywayaceue AIR HANDLING UNIT(to iii.olium) SUBTOTAL'
ag said City In consequenceof the granting of this permit.
ATR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
ignature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or future building occupant store or handle harardous HEATINGUMT(TO100,00011TU)
mated.l.,defl,.dbythe Cupertino Municipal Code,Chapter9.IZ, .dthc Date Re:ei t#
Health and Safety Cede Section25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1Yea M No ,
Will the applicant or future building occupant use equipment ordevico, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardous air contaminants.,defined by the Bay Arca Air
Quality Management District? BOILER-COMP DHP OR 100,000 BTU)
4Ya I❑''�Na
havereadthehazad.osmate a6requiemenbunderCM1aper695.f BOR ER-COIMP(OVER 100,000BT
the California Health&Safety Code,Sections 25505,25533 and 75534.I. , PAID
understand that if the building does not currently have a tenant,that it 1,my NEW RESIDENTIAL MECH. SQ.IT.
responsibility to rally the occupant of the requirements which must be met
prior to issuanre aaCertlfiate of Occupancy. JUL
14
Owner or authorized agent Date x TPB
TOTAL:
OFFICE COPY