23108 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO,
Binding Address: - G3/1^ O n
Q l8
wnerneros: .. L . + Vose: .
APPLICA LION SUBMITTAL 5KTff
.GY/ � CITY OFCUPERTINO-BUILDING DIVISION. — sse
• '° •"•" h / �L+ rc APPLICATION I PERMIT L
BUILDING-ELECMCAI.PLUMBING-MFDHAMCAL CATEGORY CONTROL X-
ArcMtect/Engineer. Llc.No:
_. QTY ELECTRIC PERMIT' • FEE BUILDING PERMITINFO
Address
PFRhIITISSUANCE ❑ . ❑, ❑
LICENSED CONTRACTOR'S DECLARATION - r
I hereby affirm that I am Reamed under provisions of Chapter 9(rommen APPLANCFSRESIDENTIAL JOB DESCRIPTION
Ingwhh Section 7000)ot Dlefelon3o(the Business and Pro(essloneC,.ode,and my � VU/ �e X
Ilam ie In fu f ra an effect. F' PANELS
Lice :y LIc.X_-=? N� ..
Date ContractorUP TO
ARCHITECI`S DECLARATION 2014000 AMPS
q�v CO I understand my plane shall be used as public mounts. OVER10AMPS SQ.FT.FLOOR AREA $/SQ.IT.
k (0 Licenced Professional SIGNSELECTRICAL _
fn 6 LFn'I - OWNER-BUILDER DECLARATION - SPECIAL CIRCUIT/MLSC
o � IherebyafBrmthat lamexempt fromthe Contractor'sLlanee Lawfwthe
ZOZO Q following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
rr,� �, countywhich requires apeuN
t to construct,alter,Improve,demolish,orcepatr
any structure prior toits Issuance,
'also requires the applicant for such permit to O POWER DEVICES t� file a signed statement that he Is Icensed pursuant to the provisions of the -
3�.1Contractors License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
don of the Business and Professions Code)orthat he is exempt therefrom and VALUATION
' the basis for the alleged exemption. Any violation of Section 7031.5 by any SO
G applicant fora permit subjects the applicant to a civil penalty of not morethan OUTLETSSWITCHISFIXTURES
five hundred dollar.($500). -
�n ❑I,as owner of the roe NEW RESIDENTIAL ELECTR SQ,Fr. STORIES TYPE CONSTRUCTION
property;rty,or my employes with wages m thele sale
compensation,Business workandtheatmdure Is not Intended oroffered for
O dale(Sec.apply
to Business f pmpcios Code:The crimp improves thereon,
License Law
3rd sonans,apply torn owner ofproperty who Wilds nemporimproovidedrroRand OCC,GROUP RES.UNITS '
whodoe. ntsach orn"ten edothrough ed ow le.1f,gees,providedthat such
improvements wldwinlen..dr.rfff.mprerle.If,h egthebuildingor
have
TOTAL; -
Improvementbeoldwithlnoneyearp(comple[ion,theowner-bulWerwlll have
tryA¢uden of proving that he did not bold or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FIDODwNE APN -
LJ L as owner of the proce
property,am exclusively contracting with licensed pggMlT ISSUANCE -/
contractors to wasteuct the project(Sec.7049,Business and Profession Code: -
The Contractor's License law does nee apply to an owner of property who —/—
ALTpt-DRAIN&VENT-WATER(EA) -
Wilda or improves.thereon,and who contracts fm dual pUojeets with a . EEE SUMMARY
INam
licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
am exempt under Sec. B k P C for this reason
— OUTSIDE FEES
DRAINS-FLOG ROOF, SANITARY Y N
Owner Date R AREA,GOND. RECEIPT X
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOLTAX Y_'N_
I hereby affirm that I have a adi8rate of consent to self-insure,w a RECEIPT N
ceAlfi"eofjWorkelWCompesatloalsumnmoramnifledmpythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800.Lb C.iA1G)117OO7-1�1 RECEIPT X
Po11ryX GAS EA.SYSTEM-OVER Com an�T� .4- BUILDING DIVISION FEES
9:u
ed copy b herebyfamished.the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Iles copy V(fled with the tlty Inspection divblon.
CERTIFICATE OF EXEMPTION FROM WORKERS' • GREASE TRAP PAID "
COMPENSATION INSURANCE
Rhlacection need CO h completed If the perm/V(Drone hundred ddollarsadollarsSEWER-SANITARY-STORM EA 200FT Date Recei t#_
($100)wless.) WATER HEATER W/VENT/ELECTR �—ys ENERGYFEE Y N
Iartily that in the performance of the work forwhich this permit is issued, ♦U V
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/17iEATING
Workers'Compensation Laws of California.Date PAID
C! Z Applicant Date Recei t#
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT,
should became subject to the Workers'Compesation providers,of the Labor TOTAL:
(A Code,you=at forthwith comply with such provlalos orchis permit shall be - I DING
W j deemed revoked. -, FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I berebyef8rm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE
M Z ane ofthe workfor which this per"is Issued(Sec.3097,Civ.C.I -
U O [ander'.Name PLUMBING FEE
LL h Lendera Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythat l have mad this application and atatethatlhe aboveinfornation
Iscomed.I agree to comply withal city and countyordinancm.adelate laws PERMIT ISSUANCE FEES PAID:
a relating to building rosteudim,and hereby authorize representatives of this
N city to enter upon the abov&mentioned property for Impection purposes. ALTERORADDTOMECH. -
? (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
V against bilines,judgments,mets and expenamwhich may In anywayaccrus AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agad By In cone isjrx2tmgkithi.Pdwy
,-2 ry � AIR HANDLING UNI'1'roVER 10,000CFM) CONSTRUCTION TAX
re of Appu rador Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
AZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date. Recei t#
Flcal[h and Safety Cade Section 15532(a)7 - - HEATING UNIT(OVER 100,0008711) TOTAL: a
❑Yee r(��J No -
Willtheapplmntor on building occupant use equipment ordevim VENTIWIION FAN(SINGLE RESID)' ISSUANCE DATE
which emit haeardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DH P OR 100,000 BTU)
Yesn No
4hava d the haze .'mar. led,regWm
reents under Chapter 6.95 of BOILER-COMP(OVER I OO,000 BTU)
the Calmad
Health k Safety Code,Sectiom 25505,25533 and 25534.1 -
understandthatifthebuildingdoesnotcurrentlyhaveatenant,that it is my NEW RESIDENTIAL MECH. _ SQ.RT. PAID ® -
resposeibllity to not the occupant of the requirements which must be met
prior to issuance of Certificate of Occupancy. (�.�1
Owner or authorized agent Data ISSUE]
TOTAL:
city Vt.
OFFICE COPY