24370 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NQ, 4 3 7 0
Building Addmaa: - Z
1 v1 lig-v of
era amu: one: A
a -5; CITY OF CUPERTINO-BUILDING DIVISION �u�
C to//n--mC'aName: No: APPLICATION /PERMIT l
V`] BMLDINr—ELECTWCALPLUMBINGMECHAMCAL CATEGORY CONTROL x
Architect/Engineer. - LIc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add.. PERMITISSUANCE ❑ - o . XO
LICENSED CONTRACTOR'S DECLARATION.
I hereby affirm that l am licensed under provisions of Chapter9(comment. APPLIANCESRESTDENTIAL - ]OB DESCRIPTION
ingwith SMion7000)of Divisim3ofthe Businew.ndProfessiona Cods,and my
license is 1.?If((Pprrecs and dfttt. -- PANELS
LicenseCks, JV LIc.M ((� T—,
Dale _Contnctrr vUP IQ 200AMPS
ARCHITECT'S DECLARATION t<r OVERI000AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
W I understand my plana shall be used as public records.
Licensed Professional SIGNSELECTRICAL
d P
OWNER.BUILDER DECLARATION SPECIALCIRCUIT/MISC � I
I hereby affirm that lamexempt fromthe Contractm.Lionvo Lawforthe /���F�
0-9_ following reason.(S ri n,70315,Business and Professions Code:Any city or TEMP,METER OR POLE INST. -
s" countywhkbrequtr apermlttomnsmd,Otcalmpmv dernlbh,ormpalr !// .L bPn
`'yOI anystmmmprlortoibWuame,ab mrequimstheappLo tforsuchper tto
K file a signed statement that he b Ilrensd pursuant to the provisions of the RAWER DEVICESto C/
r)'tic r
O u,� Contractor's License Law(Chapter 9(commencing with Section 7000)of Diel- SWPIMINC IDOL ELECTRIC JL e�Ita TrsN
H30G Mon3 of the Bu aineis and Proferelons Code)orthat he is exempt therefrom and rr-f1y�
? the basis for the alleged exemption. Any violation of Section 7031.5 by any
65n� OUTLETS-SWITCHES-FIXTURESapplicant fora permit subjects the applicant toa civil penalty M not more subjects -
c.
five hundred dollen($500). NEW RESIDENTIAL ELECTR STORIES TYPECONSRUCT10N
WWW M I,as owner of the property,or my employees with wages as their sole
F./ tempo 'atic, wllldothe work and thestruccom b not Intended or offered for -
p sale(Sec.7042 Businessand Professions Code:The Contractors License Law
�$ does not apply to an owner of property who builds or improves thereon,and IX:C.CROIR' RES.UNITS
who does such work himself orthrwgh Ms own employees,provided that such
Implo4um.Is are ror intended oroffered forwk.IL however thebuilding or -TOTAL:
improvement bmldwhhin oneyearofcompldiogtheowner-builderwill love
tht$rrden of proving that his did rwt build or improve for purpose of sale.). QTY. PLUMBING PERMIT FLOOD ZONE APNr
(J L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to cmutruct the project(Sec.7014 Business and Professions Code:
The Contractor's License Law does not apply to an owner of property when ALTER-DRAIN k VFM-WATER(EA)
buBda or improves thereon, and who contracts for a.& piojects with a FEE SUMMARY
'g11!(actor( ec.a)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under SB k P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT X
WORKMAN COMPENSATION DECLARATION f('F �.N��TRAP SCHOOLTAK Y_ N_
F-11 hereby af(Irm that I have a certlRcate of consent mself-Insure,ora —1 RECEPIM
ceaifinteof Workers Compensatimlnsurancemacedifkdwpythemof(S. GAS EA.SYSTEM-1 INCA OUTLETS PARKFE-: Y N
38W Lab C.) —
Policy 0 V 0 1 Y otT RFY_EI T N
Wm y STPPTE n TUGAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Ce M1lBedmpybherebyfumbhed. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECR FEE
Codified copy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.l00F I'. Date. Rewi t#
(Thissection need nal be completd Ithe permit b for one hundred dollars
($100)or less.) WATER HEATER W/VENT/FT,F.CTR ENERGYFEE Y_ N_
I neMNfy that the performance of the work for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYST[M/TR[ATING
Wmkms'Ccxn,r.lmLawsof Cahfornia. Date '. PAID
O Z Applicant NEW RESIDENTIAL I'LMB. SQFT. Date Receipt
Z O NOTICETO APPLICANT:If,after makingthb Certificateof Exemption,you
should become,subject to the Workers Compensns ation provisioof the Labor TOTAL:
CC N Coda you most forthwith comply with such provisions orthb permit shall be BUILDING -E
LU , deed revoked.
W me
ES CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hereby affirm that there is a construction lending agency for the perform TOTAL: ELECTRIC FEE
M Z anec or the work for which this permit is Issued&c.3097,Civ.C.) PLUMBINGFEE
(J O 1<nder.Name
QTY. MECHANICAL PERMIT FEE
LL F- Lenders Address MECHANICAL FEE
ce
U Irtify that l have read thleapplicadonand state that theabove information
O W acormn.Iagree to comply with all city and worry ordinances and state laws PERMITISSUANCE FEES PAID:
} 0. relnati.St.b.tidimg. Mai.n,andhembyauthodzempmsentativ ofthIs
F in city to enter upon the above-mentioned property for hapedion purposes. ALTER OR ADD TO MECH." Date - RCeefpt#
(We)agree to save,indemnify an d keep harmless the City of Cupertino
V against llab itles,judgments,wets and expenses which may In any way accrue , AIR HANDLING UNIT(TO 10,000 CFM) I SUBTOTAL:
against City In con nceofthe grantingofthlspemn .
AIR HANDLING UNIT(OVER 10,0110CFM) CONSTRUCTION TAX
e juju] n actorI Date EYHAUSTHOOD(W/DICT)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(T0100,000 BTU) Date - ReceI I
material as defined b the Cupertino Municipal Code,Chapter 9.1 2,and the
-
IlcalthandSafdyC sz Sect1on25532(a)7 HEATING UNIT(OVER 100,000 BTU a TOT L:
Myna , o _
Wllltheapplicare building occupant use equipment mdevices VENTILATION FAN(SINGLERESID) ISSUANCE DATE
which coot hard kwntandranteas deflnd bythe Bay Area Air
Quality Management b 7 - BOILER-COMP OFIP OR 100,000 BTU)
4�I Yes No
havcmadthehaza ousmatedas qui m n undcrChapter6.95o( BOILER-COMP(OV i100,000BTU)
L� the California Health L.SafetyCedeSections 25505,25533 and 25534.I
understand that if the building does not corrently have a tenant,that it is my N'EWRESIDENTIALMECH. -SQ.1.7
responsibility to nolltythe occupant of the requirement tsw ch mustbemet
prior roLuuua te daCcm cat olOav�pa/n/cy� /
Own liorad a.g TOTAL:
t I Date ISSUEDIYQ
'
OFFICE COPY