23100 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Peen Identification PERMITNO.
euu5gAddman: 23100
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wnera erre. j1hori i AirpucATMRITUITKITMA17A
�+t(�/tid2t�( ������ CITY OF CUPERTINOBUILDINGDIVISION
•
Co^tractoraN No: APPLICATION /PERMIT
Dff,4/W -AY�bL %x/36 BUILDING-ELECTRICALPLUMBING-ME NICALCA FSORY CONTROLN
Architect/Engineer. Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreas: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaf(Iren that l am Heresies!under provisions of Chapter 9(commenc APPLIANCESRESIDENIIAL JOB DE9CRit
ingwithSMion700Dof Dlvlalon3o(the BuMmmand PmfeasJp sCade,andmy
ilmnsc la In(Nf( d effect. �2�'1 Irl! PANELS �`�
License Class VV`"''a LIc.N (/�a t7a0 t\\,IV/a)' \TV1y�'
Date Contractor UP TO 2DOAM25
ARCHIT'ECT'S DECLARATION 201-1000 AMPS
p2 I understand my plans shall be used as public records OVER 1000 AMT'S �Q eI'.FImR4YfA I 5/9Q.FT.
Licensed Professional SIGNS ELECTRICAL E�
OWNER-BUILDER DECLARATION issahA p u /{.nr
Ej' Ihsrebyaffivnthatlam exempt(mmthe Contractors License law(or the SPECIAL CItCU1T/MIS( 'V,
7 9 '� (allowing reason.(Semon 70315,Business and Professions Code:Any cityor TpMp,METEROR POLE INS(. /
K4a@' countywhichrequlreaaper ttommtmn,alter,lmpmv dennlbh,orrepalr /���ALL
anystructure prlorto its hsuance,abo requlreatheapplicaut for such permit to POWER DEVICES YNR
�e V file a signed statement that he is licensed pursuant to the provisions of the
Conlratlori License law(Chapter 9(commencing with Section 7001 Divi-El SWIMMING POOL ELECTRIC VALUATION
O slon3ofthe BuslneuandP emlomCode)orthathebexemptthemfromand
Y.''g the basis for the alleged exemption. Any violation of Section 7031.5 by any
Q GOUTLETS-SWITCHES-FIXTURES
pj
applicant for a permit subjects the applicant too civil penalty of not more than
F five hundred dollars($SM. IJEWRESTDENTIALELECIR SQ.FT. SCORES TYPE CONSTRUCTION
/G Q I,as owner of the property,or my employees with wages as their sol
ce
ompcnsatlon,will do the work,and thestructure isnot Intended or offend for
$ O sale(Sec 7044.Business and Professions Code:The Contnnots License Law
({Sg does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFM,UNITS
EE who does such work himself or through his own employees,provided that such
Improverrents are not Intended proffered fors de.If,however,thebuildleg er TOTAL:
Improvement b wed within one year o(completion,the owner-builderwill have
thS-kurden of proving that he dM not bund or Improve for purpose ofaale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LI C as owner of the property,am exclusively contracting with licensed pEgkUT ISSUANCE a-
contractors to construct the project(Sec.7044,Business and Professbm Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improve.thereon, and who contracts for such p(ujecb with a ALTER-DRAIN&VENT-WATER(EA)
'gn1(actor(.)licensed pursuant to the Contractors License Law. FEE SUMMARY
LI I am exempt under Sec B k P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEJPI N
. WOR KMAN COMPENSATION DECLARATION FLYTIIRES�PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have is m
nNcate of..sent to self-Inure,or a RECEIPT N
ceni(Icate o(Worken'Compensatlonlnsurance aramrtified mpythereaf(Sm. GAS EA.SYSTEM-I ING4 OUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT— NN
Polity p GAS EA.SYSTEM-0VER 4(EA)
Ca BUILDING DIV]If1910N PENS
entitled copy is hereby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Cy
copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE EWER- NITARY-STORM EA.20017. ►� Date Remi t#
Qhlasectton need not be completed if the pereNt b forces hundesi dollam
($100)orless) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I cortify Nat N the perfomunes of thework for which this permit is Issued,
I shall not employ any person In any manner an as to bemme subject to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date ReceI t#
Z O NOTICETO APPLICANT,If,after making this Certificate of Exemption,you
should become.ubjcat to the WorkerCompensation provbions of the Labor TOTAL:
2 w Code,you most forthwith comply with such provisions orthis permit shall he BUILDING FEE
W > deemed revoked.
CONSTRUCFION LENDING AGENCY SEISMIC FEE
Il Ihereby affirm that there is amvtenlon lendingagency(orthe perform- OELEGTRIGFEE
2 lenZ sees ofthe work for which that permit b tvaed(Sec.3097,CIv.C.) ELECTRIC FEE
V ders Name
LL f Lender§Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 1 certifythat I have read thbappllotionand natethatthe above information
O W bcorrect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r fl relating to building comtrunion,and hereby authorize representatives o(thb
Z cit t entero n the above-mentioned propertyfor W Ion ALTERORADDIOMECH. Date Receipt#
~ city
agree eta save,Indemnify an d eemless the inspection
o1 Curpertirw
V
against liabNties,judgments,miss and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a` said - In a equerte (t grantingofthia permit.. ,
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sigratureof Applicant/C.atranor Dated Ya EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERTALSDISCLOSURE _
Will the applicant orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material an defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Flealthand Safety Cade Sedion25532(a)? HEATING UNIT(OVER I00,0WIITU) TOTA --
Yes MNo VENTILATION FAN RESID) ISSUANCE DATE
Will the applicant m futurebuilding occupant use equipment ordevices AtL,
hien emit havrdous air contaminants as defined by the Bay Area Air #'a 14
Q3Lahty Management District? BOILER-COMP OHP OR 100,0M BTU)
Yea I-1 No a�
r hlif.W t .Itha alis mat ,Si i..2550ntsundcrChapte4.If of BOILER-COMP(OVEf(100,000BN) �A 16
theerstan that
building
Code,SecHons75505ave a tenant.
It WW 1 y�
understand that lithe Wilding does notarmntly have atenanL that itismy NEW RESIDENTIAL MECH. SQ.FT. /s a
responsibility to notify the occupant of the requirements which most be met nl r
prior to Issuance of a Certificate of Ocapanry. lir �UF•Cr 1ftyl
Owner or authorised agent Date TOTAL: I55UED BY �
OFFICE COPY