23384 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bailiffs Prm'eR Idenll(icadmn PIiRMITNO.
Building Address: 0
II Ir V,I IA G'r Q 4
arta one: SUBMITTAL CITY OF CUPERTTN6BUILDING DIVISION
canna . N ue.NnS APPLICATION / PERMIT
70,
BUfLDING-ELECTMCALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/Engineer: LIB No: QTY ELECTRICPERMIT FEE BBL�UILDING PERMIT INFO
Addreae: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTR under rDECLARATION
Iherecolion70 that I am licensed under provbimnsm(Chapter9(rommen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
IkeahSect1on7000)o(DiWaon3 ofthc Buaneua dPro(esaonsCode,and my r,t IC O
iicenu ism 1 yrcea feel. r PANELS ��`(,yfa
Llcen�lic.p Ja s
Date Gmtltradmr UP TO 2DO NEES
2011000A.MPS
ARC hall be be ' DECLAR ION OVERIIDOAMPS SQ.}T.FLODR AR S/SQ.FT.
O b I understand my pians shall used w rc
publlcrords. LO
Z� Licensed Pmrfessimwl AGNS ELECTRICAL
<buy�yu OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC p j� r+ p�
j 1MrebyafBmn thatI am exempt from the Contractor's Licence law for the �] II II it 1;+— p..(
00E. followingreason. iSection7mttoBuanessandr,on rove, Code:Any dep it TEMP.METQtORPOLE INS(. t`•+s-'-,r�� -L— IL e ■
Mp county which requlresaperMtmroorequi lteq apmve,demwchprrepair ^T r� /s
a anyserodurepdortolbhat he i,alsoredpursueat to the provisions
of to POWER DEVICES DI11C i /
file a signed gatemen[that he b licensed pursuant to the provbl0w of the
Contractors License Law(Chapter9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O sion3ofthe Bunn andP miowCWe)orthathebemmpttherefromand
the basis for the alleged exemption. Any violation of Section 70315 by any
g <5OUTLE7SSWITCHESFIXTURFS
4'
applicant for a permit eubjedsthe applicant too dull penalty of not nnre than S-oo 'o D
P.,- five hundred dollars($SOUL NEW RESIDENTIAL ELECTR SQ.Fr. STOWES TYPECONSTRUCTION
tf.- ❑I,as our of the property,or my employees with wages as their sob
Q, compensation,will do the work,and the structure is not Intended or offered for
pJ sale(Sec 7004,Business and ProfOssiow Code:The Contractors License law
C.S does not apply to an owner of property who Wilda or Improves therm,and OCC.GROUP RES.UNITS
E who does such work himself orthreugh hisown employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebuilaing or TOTAL:
improvement bsokl wlthinoneyearofcompldiogtheownef.WBderwdlhave
tryLQaNeno(proving that he did not build or Improve for purposeo(sale.). QTY. PLUMBING PERMIT FEE }Tppp7DNE APN
LJ L as owner of the property,am exclusively contracting with licensed PHLMITISS'UANCE 0
rontracton to cowwd the project(See 7064,Bualnen and I'rof.10w Code: 16,00
The Contracimr's License law does oct apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereck and who contracts !or smch pSojects with a
��BB(Tactor(a)Brewed pursuant to the Contractors License Law. BACKFLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. B&P C for this reason
DRAINS HOOP,ROOF,AREA,COND. SANITARY; Y N
Owner Date RECEIPT N
t--y WORKMANCOMPFNSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_
Lo hereby affirm that I have a certificate of consent to self-insure,or a RECEIPT N
ttdiflcate of Workers Compensation Insurance ora certified ropy thered5ee. GAS EA.SYSTFM-1 WCAOUTLETS PARK FEE Y N
3800,Lab Z 1_ �^—_
Policy N � RECm'T M
Company Off 1_r'a GAS FA.SYSTEM-OVER 4(EA) BUILDING DI VI SION FI!ES
(Cert dopy -by furnished. GREASE/INDUSTRL WASTE INTQtCFPTOR PLANCHECK FEE
rtifled copy b filed with the city inspection division. ,
CERTIFICATE OF UKEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SElYER-SANITpRy-SIpRM FA.200FT. DRte RCCCI III
(This section need not M completed if the permit It formic hundred dollars
($100)mrless.) WATERHFATERW/VENT/ELFCTR D ENERGY FEE Y_ N_
I cedifyth.t m the performance ret the wok f.rwhich this permit is issued, /
I shall not employ any person in any manner so as to become subject lathe WATQ1 SYSTEM/IR ATINC
workers'Compenaationlawamfcallmmla.Dae PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei Iq
ZO NOTICE T'O APPLICANT:If,a her making this Certificate of Exemption,you
should become subject to the Workers'Compewatlmn provisions of the Labor TOTAL:
w_ Code,you most fort hwith comply with such provisions of this permit shall the BUILDING FEE
deemed revoked.
W 7 CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 O I hereby affirm that them Is a rowtwctlon lending agency for the perform ELECTRIC FEE
M Z ance of the work for which this permit es Issued(Sec.3097,Civ.C.) TOTAL:
AffO O Lender's Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I cenitythat I have read thlsapplicstionend stamthattheabmvelnforrwtion
O W rr
Is caed.[agree to comply wlthaildtyand countymrdinan
ancesd state laws PERMIT ISSUANCE FEES PAID:
} a reining tobullding construction,and hereby authorize representatives ofthb
F Z city to enter upon the abovcmentbned property for Inspection purpose. ALTER OR ADDTO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt([
V q.Jost liabllldea,ydgments,"sand ex enses which may in anywayaccom AIR HANDLING UNIT(10 10,000CFM) SUBTOTAL: a
ago id City In ronseque / nh a ottMt<pemniyl CONSTRUCTION TAX
J/ AIR HANDLING UNIT(OVER IQ0(B0 CrM)
Sig rcof Applicant onr o EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA RIXt MATERIALSDISCLOSURE
Will the appllon rfuture building occupant store orhandle hazardous HEATING UNIT(TO 100,0110 BTU) Date Recei ted
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iieaith and Safety Code&lion 2S532(a)2 HEATING UNIT(OVER IW00,0BTU) TOTAL:
yes, No
oillthex ppllont orfumre building occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air p
Quality Management District? PAID
'�BOILER-COMP OR 100,000 BTUA r A I D
4Yaann No
havemad the hazaQusmaterials requirements under Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the California Health&SafetyCode,Sections 25505,25533 and l!SSM.I
understand that it the building dons am currently have a tenant,that It is my IJEW RESIDENTIAL MECH. SQrE MAR 11 1992
ropowibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
CIlY UhUpLnunV
Owner or authorizeTOTAL:
d agent Date ISSUED BY:
OFFICE COPY