23074 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 4 PER.WTNO.
Builn79s:7p 23074 3074
ventre amp: 1W one: A
�.� CITY OF CUPERTINO-BUILDING DIVISION ^ , ,
cn ractolaNa : ` Lm.No: APPLICATION / L
PERMIT 2,4
�✓ BUILDINGELECTRICALPL(IMBINC-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addros m. . ` S� PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
lnense1SedlolUorm of Dlvffect' oHhe8uslnevand ProlessionsCode,and
license Is in(u orce and etsio PANELS
License class_ - Lk.#ontr�
Dat CHITEq] 201-1000AMIS
UP TO 2DO AN[ES
RCHITE S DECLARATION
p0�uu LicIundc ons shat as pub rc ords. OVER 1000 AMAMPS SQ.FF.FLOOR�AR I 5/J2.FT.
U en venal SIGNSELECTRICAL '; _I
Q] OWNER-BUILDER OE R SPICIALCItCUIT/MISC
pf'vla IhembyaffirmthatIamexempt(romths
in
� U T
oo following Mason.(Sedion 70315,Business and Professions Code:Any city or
O Z, TEMP.METE OA POLE]NST.
countywhich requlresa penNt toconswct,alter,improve,demolish,orrcpalr
.rn stre eortolb Lawance,aW imthea Bcantforsuch mdtto
CES
file a signed statement that he b licensed pursuant to the provislom of the POWER°� DATE
ructu
Contractor's License Low(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC '
OGG sun3ofthe Business and Professions Code)orthat he Is exem therefromand VALUATION
CY the bast+for the alleged exemption. Any violation of Section 7MLS by any OUILETSSWITCHESFIXTURFS
KKK
applicant fora permit subjeciatheapplicant to a civil penalty of net mwrcthan
F. five hundred dollars(SM. NEWRESIDENTIALELECTR
�j.. ❑I,as owner of the property,or my employees with wages as their sole SQjrr' SIONIES TYPE CONSTRUCTION
t compensation,will do the work and the structure b not Intended or offered for
5 p sale(Sec.7044,Business and Pm(esslom Code:The Contractors License Law
[ $$ docs not apply to an owner of property who builds or Improves thereon,and OCC.GAOIIP RES.UNITS
who does such work himself orthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.If,however,thebullding or TOTAL:
improvement b sold within one year ofcomptetion,the owner-builderwlll have
the rden of proving that he didrwt build orlmpmve for purpose night.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
I,as owner of the property,am exclusively contracting with llmnwd PERMIT ISSUANCE
contractors to commuct the project(Sec.7044.Businessand Professions Code:
The Contractor's License Law does not apply to an owner of property who
Wilda or Improves thereon, and who contracts for such p1o)ecs twith a ALTER-DRAIN&VENT-WATER(EM
cx7 we or(s)Licensed pursuant to the Contoeme.License Law. FEE SUMMARY
LJ I am exem order c. &P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• (Tuner Fes" to - i R_ p
RKMAN CO S TI ATION pp(NgEq PER TRAP SCHOOLTAX Y N
DI hereby affirm that I have a certificate onsent to self-Imre,or a RECEIPT#
conificate of Workers'Compensation Insurance cracettifed copy themcf(See. GAS EA.SYSTEM-1 WC.40UTLEIS PARK FEE Y N
3800,lab C.)
PoliRECEIPT#
ryq
CGAS EA.SYS W-OVER4(EA)
om any BUILDING DIVISION FEES
[�CeniRed copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
E]Cenified copy is filed with the city inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE 1 - MTAAY-STORMFA.200FT. Date Remi t#
(This sedlen need no be completed if the perms a forone hundred dollars
(gIBB)orles.> wATFR FIEATTR w/Y ./ELECIR ENERGY FEE Y N
I mdlfy that In the perfomonceof thework forwhlch this pemnit is hewed,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/.TREATING
Workerd Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLiT
MB. SQ . Date Recei t#
Z O NOTICE TO APPLICANT.If,after nuking this Certificate of Exemption,You
should become subject to the Workers Compensation provisions of the Labor TOTAL:
F W Code,you most forthwith comply with such vicloru orthh permit shall be
2 j aeemra reenkea. TI Fro BUILDING FEE
W - CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL Iherebyaffirm that there h a construction lending agency for the perform T T ELECTRIC FEE
Z ance of the work for which this permit is Issued(Sec.3097,Civ.C.)
O O lender:Name PLUMBING FEE
LL ~ lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W l cenhlythat l have read thbapplicatlonand statethat theabove Information
a Itordinances
correct.Iagree to comply with all city and county and state laws PERMIT ISSUANCE FEES PAID:
>_ N relating to building construction,and hereby authorim representatives ofthh
city to enter upon the aliove.mentloned property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agaI tit blBtin ' dgmrnts,comsand xpe seawhichmayinanyw.y.ceme AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
ago' Is ao( granting his permit.
AIR HANDLING UNIT(OVER 1Q(00CFhI) CONSTRUCTION TAX
L
SI tyre of Applicart/Contraefor Date IXHAUST HOOD(W/DIX:T) CONSTRUCTION TAX PAID:
HAZARDOUS MATE LS CLOSURE
Will the applicant or future Wilding antstom or handle hacardous HEATINGUMT(TOl00,0WBTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCode�+.-S�ection 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: 2�-107-
❑ Yes L_I No
Willthe applicant orfnum Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hainrdousalr contamiruntsas defined by the Bay Area Air
• Quality Management District? BOILFR-COMPOMPOR 100,000 BTIn f# h
Yes n(� P M Q No
have read the It aaaimous materials rcqu lremnnb u oder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sect Ions 25505,75533 and 25534.1 ®EC =6
undersondthatntify the the occupant of to currentlyhavewhich
that it hmy NEW RESIDENTIAL MECIi. SQ.IT. 19notporea (19 (1�
understa ndtatity to notify the occupant does net curequly have awhichmust be Itotm 1 D1
prior to lases nm of a Certificate of Oecu pa nry.
G( Gar HIIIVU^
Owner or authodred agent Data ISSUED B Inw—I
TOTAL:
OFFICE COPY.