23909 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hultding Project Identification PERMIT NO.
Building Addreao 23909
22 a PIFN.erl Q
neve came: one: p .
CITY OF CUPERTINO�BUILDING DIVISION
contractor,Na Lic.No: APPLICATION I PERMIT (s —jj�•-�
BUILDING-ELECnUCALMUMBINC-MECHAMCAL CATEGORY CONTRCt?6I
Amhite t/Fngfneer. Lk.No: (��1.
` QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE I � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby afirrnthat l am licensed under provisions of Chapter 9(mmmenc APPLIANCESRRSIDENTIAL OB DESCRB'RON
Ingwith is ien allionorforce
)of an effect
fectMo fthe Busess
nand ProfessionsCode,end my
license
d e PANELS
License Class Lie.N
Date Contractor UP TO 2DO AMPS
ARCHITECPS DECLARATION X11-1000AMI5
quq�au K ZO I understand my plansshall be used as public records OVER 1000 AMPS SQ.PT.FLOOR AREA $/SQL.FT.
Fi Z 0 Licensed Professional SIGNSELECTRICAL S�
<Q OWNER-BUILDER DECLARATION
O O SPECIAL CIItCUfT/MLSC
f., Ihercby affirm that lam exempt from the Contractorb License law for the
following reason.(Section 7031.5,Business and Pro(essbns Code:Any city or TQdp MEFER OR POLE!NSP.
county which requires a permit to construct,alter,improve,demolish,or repair
Cal anystmcture prior to its Issuance,also requires the applicant for such permit to POWERDEVICFS
c 5
ilk a signed statement that he Is licensed pursuant to the provisions of the
Contractors License (ChapterLaw 9(commencin with Section 700D)ofDivi-30C' sm.3oRhe Businessand ProfeionsCode)orthatt hebexempttherefromand SWIMMING IT OLE ECRC VALUATION
5 the basisfor the alleged exemption. Any violation of Section 7031.5 by any U OUTLETSSWITCHESFIXTURESsaa
applicant fare permit subjects the applicant to a civil penalty of not mare Ilan , RI �s
p, five hundred dollars($500). NEW RESIDENTIAL ELECTR EQ.FT, STORIES TYPECONSTRUCTTON
�n as owner of the property,or my employees with wages as their sole
co pensa0on,wllido the work and thestmcture b not intended or offered for
nas e(Sec.7044,Business and Professions Code:The Contractors License Law
t?jQ does not apply to an owner of property who builds or Improves thereon,and OCC.CROUP RFS.UNITS
E who doessuchworkhirnselforthraugh hisown employees,provided that such
Improvements are not intended oroffered forsele.If,howeveq theWilding or T
Improvement issold wdhinoneyearofcompinlon,the owner-bullderwill have
the rdenof provmgthm he did rot wild mimprove for purposedsais.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L°L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-ORA W kVENT-WATER(EA)
wilds or Improves thereon, and who contracts for such projects with a FEE SUMMARY
,,11BBfIactor(,)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B 6 P C for this reason 'FEES
DRAINS-FLOOR,ROOF,ARECOND. SANITARY Y N
Owner Date A, RECEIPT N
WORKMAN COMPENSATION DECLARATION
F-11rm FIXTURES PER TRA!' SCI400L TAX Y N
1 hereby affithat I have•certl0ate of consent to self-Insure,or RECEIPT N
certificate ofWorkeri Compereution Insurance me certified mpythereof(Sec. GAS FA.SYSTEM-1 WC4OTTLETS PARK FEE Y N
3800,lab C.) —
RECEIPT N
I'olkyN CAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISI FEES
Com raCey nified copy b hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE rj
Certified copy b filed with the city inspection division. L a
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.200FT. Date e<:el t#
(This section need not be completed lithe permit is(or one hundred dollars
($100)0rloas) WATER HEATER W/VEM/ ENERGYFCE Y N-
1 cemfythat in 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 WATQt SYSTEM/
Workers'Compensation laws of California, Date PAID
02 Applicant .pr, �. Remi t#
Zmaking
O NOTICE TO APPLICANT.I(,after this Certificate of Exemption,you
shmld become subject to the Worker,'Compematlon provblov ofthe tawr TOTAL.
N Codgyournu,Iforthwith comply wlthsach provisions orthla pemdtshall be s B IL G
W j deemea revakea.
CONSTRUCTION LENDING AGENCY S ISM FEE
d Z I hereby affirm
orkforthat whit the.b a con it is in n ld(Sec. 097,Cie.
pertorm TOTAL: EL RIG 1'E•
02 arm Lender Nwork(orwhkhthbperntblasued(Sec.3097,CIv.C.) PLUMBING FEV
-
LL
lenders Names
LL N Lender,Addmss QTY. MECHANICAL PERMIT FEE MECHANICA FEE
0 W 1odifythatl have readthisapplicationan statethattheabove information
1 becreect.l agree to comply with all cityand county ordinances and sate laws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and hereby authorize representatives.(this
F N city to enterupon theabove-mentioned property for Inspection purposes. ALTERORADDTOMECH.
V Z (We)agree to save,Inde n d keep harness the City of Cupeniro Date Receipt#
against Ila IBn,N and expenses which may many yacaue AIR HANDLING UNIT(f010,UK)CFM) BTOTAL:
againa eceoft an hlspe
nCO AIR HANDLING UNIT(OVER 10,MOCFM) CONSTRUCTIOrkTAX
Weq.1preemcudevices
of v t ontractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
NA USMATERIALSDISCSUsupplicant to ulldingescvpantst or ndlehavardous HEATINCUMT(TO10BODOBTU) Date of t#sciefined t Cups mM.nldpal CodaCh c,9AZa.dthe 4d Saf nion 32(1)7HEATING OMT(OVER 100,000 BTU T (t�.Noe cap �m car lutum buildi occupant equlpreemcudevices VENTILATION FAN(SINGLE RESID) ISSUANCE ATE
t ousalrmntannanaa by the Bay Area Air
aragemcnt Distrin7 BOILER-COMPPIIPOR100,000BTLnp nn No P A 8 D
madthehuam�ousmaterialsrequirementsunder Chapter 6.95of BOILER
-COMP OVR103,0008TU)
the California Health 4c Safety Code,Sections 25505,75533 and 25534. 1
understand that if the building docs not currently have a tenant,that it is my NEW RESIDENTIAL MECii. SQ.PI JUL
responsibility to notify the occupant of the requirements which must be met an
prior to issuance of a Certificate of Om pa ncy. a
Owner or authorized agent Date ISSUED it TOTAL: MVV
VM r
TOTAL:
OFFICE COPY