21879 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prosed Identification PERNITNO.
BuildingA 8 el A)roRTy i,/Evj LT21879
1 Oe"umat: am APPLICA HON SUBMIFIAL
t)X
_-2 s'6CITY OF CUPERTINO,BUILDING DIVISION
Contranor a Name Lie.No:
APPLICATION / PERMIT -Zg�
w BUILDINGELECTRICA[.PLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: ` PERhIT[SSUANCE MW ❑ ® ❑ ❑
LICENSED CONTRAROR'S DECLARATION ofCh ON
I hereby albmehafDiv1km3ofthr uNne blonsofChapten9(rommmc APPLIANCESRESIDENTIAL JOB DESCRIPTION
It...I rction I.fullforcea Divfect. (theBusinemandPro(esslonsCode,andmy SPf� `
license Is In tuff force and effect. PATOIS - c \r..F�J:T
License Clam Lk.N
Date Contractor
ARCHITECTS DECLARATION X0 AMPS
re0 7 ]understand my plans shag be used a public records OVERVER I 1000 AMIPS SQ.FT.FLOOR AREA $/9Q.Fr.
O
Licensed Profenlotul SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION I SPECIALCItCU1T/MISC 1 r
i.,�a Ihereby affirm that am exempt from the Contractor's License Law for the
59ga following mason.(Seetion 70013,Business and Professions Code:Any city or TEMP MMTR ORIPOLE[NST.
app county which requlresa permit toconstruct,alter,improve,demolish,orrepur
El �Q any stmctom priertoiGLswancgalsoreq.1re.1heappBcantfo...ch permit to POWER DEVICES
a U Ole a signed statement that he b licensed pursuant to the provisions of the
Contranor'.License Law(Chapter 9(commencingwith Section 7000)ofDWI- SWLNMINGPOOL FLECTRIC VALUATION
O<< sion3ofthelhalnessand Professions Code)orthathelnexem iherefromand
t✓ y.'Y the basis for the alleged exemption. Any violation of Section 7001.5 by any .
OUTLETSSWITCHESFIXTURES
Lv'[� a Brant for aperlleged subjects penalty of not mare r. O asp ehyndred dollars($500). SQ STORIES TYPECONsrFucT10N
,g. "j`,' NEW RESIDENTIAL ELEC7R Ff'.
fh?�A as owner of the property,or my employes with wage a there sole
zc.7WZ Bsuflo usiness work Profen orstrunure is he Contactorntended or License
ed for
Law
0O sale(Sec.704y Business and Profenlons Cade:The Contractor's Llrense law
(j5$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
EE who doessuchworkhimseiforehmugh hisown employees,provided lhatsuch
Improvements are not intended orofferedforsale.If,however,thebuliding or TOTAL:
improvement bsold withinoneyearofcompinion,the owner-W11derwlll have
th� rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
1!TI,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor's License Lew does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(G)
Wilds or improves thereon, and who contracts for such p�ojens with a
cg11S[anor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y_ N_-
Owner Date RECEIrN
WORINIAN COMPENSATION DECLARATION FIXTURES]'FR TRAY SCHOOL TAX Y_ N
❑I hereby affirm that I have o mmficete of consent to opytheure,ora RECEIPT N
3800,Lab o(Workess Compensatlonlnsurance ma certified copythemof(Sec. GAS EA.SYSTEM-]INCA OUTLETS PARK FIX Y N
3800,Lab CJ
Policy N RECEIPT N
Cam any GAS EA.SYSTEMAVERI(FA) BUILDING DIVISION FEES
CertlOed copyb hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF EKEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date RCCfI t#
(Thissection need not be completed if the permit Is forom hundred dollars
($100)or les.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certifythat In the performance of the work for which this permit Is blued,
1 shall not employ an/person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should became subject to the Workers Compensat Ion provisions of the Labor TOTAL:
(n Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
>
deemed revokd.
e
W
a g CONSTRUCTION LENDING AGENCY SEISMIC FEE
]hereby ffirmthatwork for
them beconstmctiond(See ag7,Civ. .) perform TOTAL: ELECTRIC FEE t '✓
� Z ance of the work!car whkhthis permit is issued(Sec.3097,Civ.C.)
(� O Icnder'.Name PLUMBING FEE
LL I- [.cider's Address QTY. MECHANICAL PERMIT FEEPLUMBING
FEE
O I certlfythat I havemad this application and nutethattheabove Information
O W iscormet.I agree to comply with all city and county ondlnanes and state laws [PERMIT ISSUANCE FEES PAID:
>. a relating to building construction,and hereby authorize representatien of this
(— U) city to enter upon the abova.mentlond eproperty for inspection purposes. ALTERORADDIOMECH.mDate Receipt#
(We)agree to save,Indenify an d keep harmless the City of Cupertino
V against liabilities,/rdg.rt.,co.is and c.Faen which may In any wayaccme ATR HANDLI NG UNIT(TO 10,000 CFM) SUBTOTAL:
agaiwe Ity Incon gran gof this pennB' CONSTRUCTION TAX
/ AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contrano Date EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS IvE&TERIALS DISCLOSURE
Will the a pplicant or future building oeti pant store or hand le huardous HEATING UNIT(TO 100,000 BTU) Date Rotel t#+
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the - O
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: I I E SW
❑Yes M No
Will the applicant or futura building occupant use equipment or device VEMIILATION FAN(SINGLE RESID) ISSUANCE DATE
which emB havardous air contaminants as dented by the Bay Area Air
Qua lily Management District? BORER-COMP QH POR 100,000 BTU)
Yes ❑No ��/
M
00 4havcreadtheb..9.usmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) w
the California Ilcalth&Safety Code,Stolons 25505,25533 and 25531.1 C
understand that iftho Wildingdoes not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT. rEg
raPortability to notify the occupant of the requirements which must be net D Js?
prior to issua ace of a Certificate of Ocaupa ncy.
Owner or authorlad agent Date TOTAL: ISSUED BY: ""✓" "'---�C�"�
OFFICE COPY