23875 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMiTNO.
BuBding AdareI '?SLt 23875
nen e;
CITY OF CUPERTINO-BUILDING DIVISION
Contractor' oma: _ n Lic.Na: APPLICATION /PERMIT
Amhltcct/Englruer. O"+-�LBUILDINGELECTRICALPLUMBING.MECHANICAL
CATEGORY CO.
Llc No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc. APPEANCESREEDENIAL JOB DESCKHMON
Inensei infull force and ied. o(the Butlressand Professions Code,and my
Incense binfunforceanddfed. PANELS
Limn.Claes LIC#
Date Contractor UP TO 2DO ANTS
ARCHITECT'S DECLARATION 201-1000AMPS
aO ZpC l understand my pla..hall be used as public temtds OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
zU Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
t;� SPECIAL CIRCUIT/M1SC
F Iherebyafflrm that l am exempt fromthe Contractor's License Law for the
7.Q following reason.(Section 70ILQ Business and Professions Cade:Any dty or
O Z"a TEMP.METEt OR POLE INST.
P5 county which requires a permit tmmnstmct,shot,Improv,demolish,armor
anystm=m prlorto its Wuance,alao requkeatheappllam forsuch permit to POWER DEVICES RSA 4
U file a signed statement that he is licensed pursuant to the provisions of the _ ,) J
S ty 1l.� Contractors License law(Chapter9(commencing with Section 7000)of Divi- /
H Ili sion3ofthe Buslnessefid ProfessionsCode)orthat hegmatpttherefromand SWIrfMINC IDOL ELECCRI - la LUA Oyh5_
Q.•�33 the basis for the alleged exemption. Any violation of Section 70)15 by any OUTLETSSWITCHFSFI%711RE5it
-4EjS
P � G��
appllcantforapen tsubjecbtheapplkant/oadvllpemltyofnatm mthan SO _�
Q vs, ndred dollars($500). FS _ j TYPE CONSTI2DG'IIDN
u NEW R[SB)FMIAL ELECTR I ,Fn,FT:' s
WWW �n as owner of the property,or my employees with wages as,their talc
m pc gimwllldotMwork,andthesttuctureisnot intended or offered for IE
D e(Sec.7014,Business and Professions Code;The Contractors License Law
3$ d as not apply to an owner of properly who Wilde or Improves thereon,and OCC.GROUP RES UNITS
whodcessuchworkhimeelfmth=ghhis wnemployen,providedthatmch
ofimprovements arenot Intended oroffered forsale.If,however the W Ilding or TOTAL:
improvement bsold within one yearof completion,the owner-builderwill have
IhiLtIurden of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD-IANE APN
Lf I,as,owner of the property,am exclusively mntmami;with licensed PERMRISSUANCE
contractors to mns(mct the project(See.7014,Business and Professions Code:
Tie Contractors License Law don not apply to an owner of Property who ALTER-DRAIN&VENT-WATER(EA)
builds or improves thereon,and who contracts for such ptolects with a FEE SUMMARY
�gp(rador(s)Bcamed pu rsu"t to the Contractors License Law, BAIX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this recon
DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECERT p
WOR KMAN COMPENSATION DECLARATION Ff1(TIIRES PER TRAP SCI{OOL TA% Y_ N_
of
hereby affirm that I have•mNifiate of consent to xeB-Insure,or• RECEIPT#
certillateo(Workers'Comperuatimlns mnmmacedifiedmpythemof(Sec.
3800,Lab CJ CAS EA.5YS1'FM-1 WC.60I7ILEfS PARK FEE Y N
Policy# RECEIPT#
GAS EA.SYSTEM-OVER d(EA)
Company BUILDING DIVISIO F.CS
1 1 Certified copy b heed with the city GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK F'
L�Ji Certs(led ropy b filed with IM city Inspection dlvlslon. ���
CERTIFICATE OF IX EMPTION FROM WOR KERS' GREASE TRAP PAI
COMPENSATION INSURANCE
Crhissectionneed notbeeomplded lithe permit b for one hundred dollars SEWER-SANITARY-STORM EA.200FT. to Recti t#
($100)orl tha performance]aor l in the per(oance o(the work forwhkh this permit Is lamed,
WATER HEATER W/VENT/ETR ENERGY FEE Y
I shall not employ any person in any manner an as to become subod to the WATER SYSTEM/TREATING
Worken'Compensatlon Lawsof Callfomla.Dale PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQYf. Date Remi t#
Z NOTICETO APPLICANT:ILafier making this Certificate of Exempuon,you
Fshould becomesubject to the Workers''Compensation provisions of the Labor TOT L:
a. W Code,you must forthwith comply with such provisions orthis permit shall be 1
W 7 deemed revoked.
F3 1 CONSTRUCTION LENDING AGENCY $EIS
a efth. orkfa hatlMre bammittutlian lending age097,cy for Civ.
perform E I ' E
� Z ancealthe work far which this perMtbtuued(Sec.3097,CIv.C.) TOTAL:
U O Lenders Nacre PLUMBING FEE
LL I— Mnaer.Aaamaa QTY. MECHANICAL PERMIT FEE MECHANICAL
O W Icertifythmlhave read this applicatbnend statelhatthealamminlommian -
1 isconect.I agree to cmmplywith all dtyand county ordinances and pate Paws PERMIT ISSUANCE "PAID:N relating to building consWRlon,and hereby authorize repesenbtives ofthisF Zcity to enter upon the abovcnenllorad property for Wpection purposes. ALTER OR ADD TO MECH. Cel [#Z (We)agree to ave,Inst ly and kat armless the City of Cupertinoa gainetllablllies,I,dgmenta,cot dexp n¢ whlc inanywayaccrue AIR}iANDLiNC UMTCTO 10,000 CFM) SUBT AL'nc ofthagr t epe it APR HANDLING UNIT(OVER 10,000CFM) ONTAX
rc of Appu ranor � E(HAUST HOOD(W/DLK:T) CONSTRUCTION TAX PAID:
HAZAR DOLS MATERIALS DISC SURE
Will the applicant or future building occupant store or hand lc hazardous, HEATING UNIT(TO 100,0(10 BTU) Date Reeei f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I kalt hand Safety Cade,Sedlo
on n25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Wthe applicant or❑future building ocmpanlunequlpmentordevicn VENTILATION FAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air contaminanlsas defined by the Bay Area Air n B
Quality Management Diatrlct7 BOILER-COMP OHP OR IG0,IXD BTU) 4+1
F�)Yn No
ave read the haza ous materials requlremento underChapm,6.95af BOILER-COMP(OVER 100,000 BTU)
the GlBomia Health A Safety Code,Sections 25505,25533 and 25534.I JAN
1!1(9
unaentand that if the building does not mrmatly have a tenant,that It is my NEW RESIDENTIAL MECH. MVV SQ.FT ..77x77
responsibility to notify the occupant o!the requirements which moat be met
prior to Issuance of a Certificate of Ottvpancy. CITY OF CUYG
Owner or aulhm trod agent Data
TOTAL: ISSUED OV:
OFFICE COPY