21989 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building AddmB9ildin Protect Identification PI9tMITNO,
oa3 e S 21989
ante. n A A A
CITY OF CUPERTINO-BUILDING DIVISION Q
contractgYSRaix: Lic.No. APPLICATION /PERMIT — L
BUfLDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑ ❑
LmtLASED CONTRACTOR'S DECLARATION
There Section
ivsti.0duallu rov.rdPro Cha r9(commenc API'hIANCFS-RFSIDENTUL
by P Pte JOB DESCRIPTION
IngwRh Settlors force)anDivfect. the BuslneuandPro(esslonaCode,and my, PANELS �Q V.P,— �l(reak
license Isinfull form and c.#
LicenseClass Cort
Date Contractor UP TO 2DOAWS
ARCHITECT'S DECLARATION 211-IODOAMPS
0 2 I undemtand my plain ahaB be used u pubbc records OVER IODO AMPS .FT. OOR AREA a f/SQ.FI.
O SIGNS ELECTRICAL C Vl `N L� D 1
du�
m V 0j Licensed Professional
6 OWNER-e UILDER DECLARATION SPECIALCIRCUIT/MISC e
IhercbyatOmnthatlem exemptfrom the Contractor's License Law for the /�i1h/ /.e
O�FF� cruntyngichregtmaprittocosinenand Professions Code:Any �1
.p TEMP.MEFFR
W ntm hmp griolts erndttocommqu alter,theaImprove,
ntforsbh, er tt
pair
any sweturetatemeltmhathe ,ebosed Pursuant
the forsuco"of to ROWER DEVICES
Ole a signed statement that he U r 9e(com pursuant it the ? ns of the e- S`
ContractorbLlceueLw(Cupter9(commn(commencingSection 7000)ofDvl- SWDUJNGPOOL ELECTRIC
O sbn3of Ne Busmemand Pro(esslom Code)orthathebexempttherefromand VAL l
q Q,SS, the basis(or the alleged exemption. Any violation of Section 7031.5 by any OU7LMSWITCHESFIX TURFS
�O
applicant for a permit subjeto the applicant to a civil penalty a not more than
five hundred dollam($500). NEW RESIDENTIAL ELECIR BQ�.
7
E]1,as owner of the pmp orty,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,will doth work and the structure b not Intended or offs difor
qsale(Sec.7044,Business and Professions Code:The Contractors Llcense Law
5$ deem not apply to an owner of property who builds or Improves thereon,and OCG GROUIs RFS.UNITS
who docs suchwork himself or through his own employees,provided that such
Improvemcnb are not Intended or offered for sale.If,however,the build ing or TOTAL:
Improvement bsold withinoneyearofcompletion,the owner-builderwill have
it under,of proving that he did not build or Improve for purposeofuleJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcontractorsto coustmct the project(Sec.7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
bunds or Improves thereon, and who contracts for such pSujects with a FEE SUMMARY
tractor(a)licensed pursuant to the Contractor's License Law.
cam exemptunder Sec
B 4 P C for this reason — BACK FLOW PROTECT.DEVICE
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
• Owner Data RECEIPT N
WORIU4that COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAR Y N
❑1 hereby affirm that I have ocertificateInsurance
c of consent to copy
ora RECEIPT'N
ceriffM00,1MC.of Workers'Compemationlmuranaoraartlfled copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARR FEE Y N
Policy
lab CJ RECEIPT N
Polley N GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION Fr.ES
Ce
MiBed copy is hereby fumished. GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
❑Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA XIOFT Date ReceI t#
(rhlssectbn need not be completed If the permit bfor arm hundred dollars
(Sloo)orpem.) WATER HEATER W/VFM/ELECTR ENERGY FEE Y_ N_
1 artifythat In the pertomuncrof the work forwhlch this permit Is blued,
I shall net employ any person In any manner so as to bemme subject to the WATER SYSTEM/TREATING
Workers Compn G
ensatiowsof Callfomia.Date PAID
O Z Applicant NEW RFSIDFMTAL PLMB. SQFf. Date Recei t#
Z O NOTICETO APPLICAMa, orlum'Comhb Ction Preo(Exempt Labor
should become subject m the Workers'Compewtlon provbbm o(the Labor TOTAL:
H rn Code,you most forthwith comply with such provisions orthis permit shall be BUILDING 'E -0
CC
deemed revoked.CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Iherebyaf@mthat there is a construction lendingagency forthe perform E
F
L
TOTAL: ELECTRIC E
Z once of the work for which this permit b boosted(Sec.3097,Civ.CJ ELECTRIC EEE
02 Icndcr'a Nacre MECHANICAL PERMIT FEE
LL F Tendert AahatI t MECHANICAL FEB
O W lcedify tagreet complye read is with all city and county
or inn abovedgateaaws
M is correct.building complywo ,aild hereby
auhomae,manes and gate PERMIT ISSUANCE FEES PAID:
} releting to oenterupon t construction, rcby authorize representatives of this
F Z dl(Wo)aeree to the,Indemnify an
propertyforInspection Cit purposes. ALTER OR ADD TO MECH. Date Receipt#
(Wo)agree to save,indemnify andlump.;,vo. hickeas the in any
Ou w.y. a AIRHANDLINGUNIT(TOI0,000CFhQ
V against llabllltica,N grnenb,costs end expenses which may In anyway accme SUBTOTAL:
again ul Cicon oto granting of this Permit.
-•n aRrunmuFrc lm'1T(ovER lo,aao cFvf) CONSTRUCTION TAX
ignature (Applicant/Contractor C,[L•f/�V Date EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or(utum building co,upant store or handle hazardous HEATING UNIT(TO 10),000 BTL) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12 and the
Health and Safety Code Section 2S532(a)? HEATING UNIT(OVER lWXx BTU) TOTAL: J D
Cl Yds MN.
Will the applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
miha
which et zardous air metam name as defined by the Bay Arca Air
Qua lily Management District? BOILER-COMP(31M OR IWOM BTU) PAIS)
Yea
4 ❑No
haveread the hazardowmaterials requirements uoder Cho pier 6.95of BOILER-COMP(OVER IW,01a)BTU) AOR
�YMasNs•Htl,•1g1
the California Health k Safety Code,Sections 25505,25533 and 25534.1
understandthatlfthebuildingdoesnonmrrentlyhaveatenant,thatitbmy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met �aa,as�:
prior to issuance of a Certificate of OaMilesYvpancy. d&Wfife
Owner or authodzed agent Date TOTAL: ISSUEDBY: .A U:D
1
OFFICE COPY /