21893 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pron, Identification PFRMMTNO.
BuildingA_gI - - 21893
'2.a l'I 9 ��WCI� Q J tl�.�
r ners ame: one: APPLIC776=11PT771=A
CITY OF CUPERTINO-BUILDING DIVISION
• Conhacto .Name: LIe.No: UfAPPLICATION /PERMIT
S 3� BLDINGFI,ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLX
Architect/Engineer. Lie.No:
�c QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreas5V` (� 6 (L PERMITISSUANCE ® El ❑ ❑
LICF.NSF.D CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comerenc APPLIANCESRFSIDENTIAL JOB DESCREMON
Ingwith Sedion 7000)of Dlvision3ofthe Businessand ProfessionsCode,and my
license is int 11 in d`effect. 3s9 PANELS 1
Date Contractor
ARCHITECPS DECLARATION 2014000AMPS
�7 I understand my plans shall be used as publleeemNs. OVERI000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
E Licensed Professional SIGNSEL.ECTRICAL
Q w OWNER-BUILDER DECLARATION
C SPECIAL C RCNT/MLSC
l., Thereby afftrmlhatlam exemplfromthe Contractors License Law for the
lz following reason.(Section 7031.5,Business and Professions Code:Any city or
p p, TEMP.METER OR POLE INST.
�
county which requires apermit to construct,alter,Improve,dertnlbh,orrepilr
F v anyatrornrre prbrto ib i,aaance,atw requireatheappBcantfor such perrtdt to POWER DEVICES
Vfoe a signed statement that M Is licensed pursuant to the provisions of the
3µi Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O aion3 ofth,Bushes,and Professions Cade)mthat he is exert therefromand
h G S the basis for the alleged exemption. Any violation of Sections 7011.5 by any OIITLETSSWITCHESN)CIVRES
applicant for a permit subjects the applicant to a dell penalty of not mtl
oreun
five hundred dollars(¢500). NEW RESIDENTIAL ELECTR t SQ.FT. STORIES TYPECON'SIR(1CTION
owner of the property,or my employee with wage a,their wle
�7Q compemation,ZZothe work,and theatruaure is not intended or offered for
5 O sale(Sec.7044,Business and Professions Code:The Contractors License law
$ does not apply to an owner of property,who builds or improves thereon,and OCC.GROUP RFS.UNITS
who doeswchwork himsetinrthrough hisownemployess,provided that such
Improvements am not Intended oroffered for sale.If,howevegthe building or
Improvement Issold within oneyearofcompletion,the owner-builder will have
th,tpnrdenof pmvhg that he did nm builder Improve for parposeofwN.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LI L a,owner of the property,am exclusively contracting with Roinsed PERMIT ISSUANCE
contractors to construct the project(Sec 7004,Business and Professions Code:
The Contractors License Law dm not apply to an owner of property who ALTER-DRAIN&VEM-WATER ffN
builds or improves thereon,and who contracts for such projects with a FEE SUMMARY
Cg1Lt[actor(.)licensed pursuant to the Contractor.license Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,ARE A,CONTI. SANITARY Y_ N_
. Owner Date RECEIPT'a
KMA
WORN COMPENSATION DECLARATION FIKTURES.PER TRAP SCI;OOLTAX Y_ N_
0
1 hereby af(Irm that I have a wrtiflwte of consent to sell-Teem,or a RECEBxf 0
mrtlficate of Workess Compensation Insurance ma cectlfled copythereof(Sn. GAS EA.SYSTEM-11NCA OUTLETS PARK FEE Y N
3800,Lab CJ REC=a
Policy R GAS EA.SYSRRd-OVER 4(EA)
Coma BUILDING DI VISION FE ES
�ified copy is hereby tCREASE/IN'DUSIRL WASTE INTERCEPTOR PLANCHECKFEE
Certified ropy V filed withh the the city
Inspection division.
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200F1', Date Recci t#
(Thlssection need nm be completed If the permit V forone,hundred dollars
($lW)mlcss.) WATER HEATER W/VEM/FLECTR ENERGY FEE Y_ N_
I mmitythat in the performance of the work for which this permit h issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PIMB. SQFf. Date RL i t#
Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
2L' should beconesubject to the Workers Compens.tlon provielons of the You
TOTAL:
� L Cod¢,you..at forthwith comply wlthsuch provtsiom mthis pemmtshall be BUILDING ITE aC)O
W > deemed revoked. Sff
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE t
S O I hereby afOrnthat there is a construction lending agency for the perform- ELECTRIC FEE
O !<nZ anoe ofthe work for which this permit isisaucd(Sec.3097,Clv,C.) TOTAL:
U aer.Name PLUMBING FEE
F Lender,Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W comet.
Iagretoco ply bi with
all citynand dcoutethatthe yordinances and
CL isgt Iagreeto complywo ,andtyandcountybe,representative,
and gate laws I'ERMITISSUANCE FEES PAID:
} cityrelatenteruild pon t ronsove-mn,and dproprtyoNtreptesenpurpos oflhb
F to city enter to the above-mentioned property for Wpe Cit purposes. ALTEROR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cuperthe Date Receipt#
V .,alnstll tics,' dgmora stsa xpenses which may In anywayaccme AIR I;ANDLING UMT(TO 10,000 CFM) SUBTOTAL:
a airs itroe encs t granting this permit.
AIR HANDLING UNIT(OVER 10,MoCIM) CONSTRUCTION TAX
51 mtureo(Appliont� Tactor Date EKHAUS'T HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA DOUS MATERIAL5 DISCLOSURE
Willtheappticam rfutuu
m building occupant store or handle hardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
materiala,defi.M ythe Cupertino MumtlpalCMd,Chapter9.i2,andthe
Flealthand Safety Code Section25532(x)2 HEATING UNIT(OVER 100,000 BTU) - TOTAL: Sl LIC
Yen
No
❑Wlltheappllcant o�ture building occupant use equipment ordevices VEN'ULATIONFAN(SINGLERESIU) 1$SE DA'Z'E
which emit haaardous air contaminants as dented by the Bay Area Air ��'
• Quality Management District? BOILER-COMP OFR'OR 100,000 BTU)
Yea (�No (t AA7
have read the F mous materials requlmments under Chapter 6.95 of BOfI.ER-COMP(OVFR 100,00(1 BTU) :1T( y 071
the California I lealth&Safety Code,Sections 25505,25533 and 25534.I
understand that If the building dues not currently have.tenant,that it la my NEW RFSTDEN77AL MECH. SQ.FI.
responsibility to notify the occupant of the requirements which must be met 14IgNu oaf AlaNv►iM _
prior to Issuance of a Certificate of Occupancy.
Owner or authmiud agent Date
TOTAL:
OFFICE COPY
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