23575 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuildingProject PERMIT N
Pra Identification O.
BuOd Ng Addi 1Q ` 23575
APPLI=57=11 IAL
CITY OF CUPERTINO-BUILDING DIVISION
Contmenr'.Oak cis.Na APPLICATION ( PERMIT
Archlted/Engineer, Lk.No: 81RLDING-E.F-CTRICAI PLUMBING-MECliANICAL CATEGORY CO
QTY ELECTRIC PERMIT FEE BUILD INC PERMIT INFO
Addresa: PERMITISUANCE r 1:1 1:1LICENSEDCONTRACTOR'S DECLARATION
I hereby offUm that lam licensed under provisions of Chapter 9(comment, APPEANCESRESIDENIAL JO DFSCRIPHON
Ing with Sectio 72W)of Division 3 ofthe Buslnessand PmfessloesCade,and my 1..
license Is InfuI andeffect. Q PANES
Licese�a Lie.M
Dal �G f0 Conmxtar,1—!T!" UP TO 200AMPS
ARCHITECT'S DECI.A ATION 201-1000 AMPS
ce0 Z I and rat m lam eha0 used ublic records OVER IOW AMPS SQ.FT.FLOOR AREA $/SQR.FI.
6: Llan ev anal SIGNSELFCTRICAL 2 V O 78
<�6 RBUILDER CLARATION SPECIALCIRCUIT/MISC 6S
I. (hereby affirtnl)h ulle
amxempt ER the Contractors Lkenss Law for the a
following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP METER OR POLE(NST.
countywhich requires a permit m oorutruct,alter,improve,demolish,orespair
anystrucNre prior to its issuance,also requlrealheapplicant(orsuch perndtto POWER DEVICES
file a signed statement that he b licensed punuant to the provbiom of the
3u,I. Contractor's License Law(Chapter9(commendng with Section 7000)of Divl. SWIMMING IDOL ELECTRIC VALUATION
EO% .ton3o(the Businessand Professlom Code)orthat he is exempt therefrom and ��, 891
< the basis for the alleged exemption. Any violation of Section 70HS by any OITMETSSWITCHES IXTURFS �e
applicant fora permit subjedatheapplit"I to a civil penalty of net recrethan d
fRI.•577 fivehundreddollars(SM. NEW RESIDENTIAL ELECTR
I,as owner of the property, �'FT' STORIES TYPE CONSTRUCTION
�n ❑ p ork,a or my r offered
sole
compensation,wiii Bosdoltsworkandthes Code:
mmntract r orofferedfor
93 sale(Sec. pply 70K to alnown.andf property
Code:The or Imp dols ves hemonLicense Law
[ �R whodoes o's such loan owner o(propehhbo nem orlmproovidedreoryand that such OCC.GROUP RM UNITS
wprovemuch se,not himself edoro erhl•ownemIf,ho e er,Out wilding or
improvement•arenot Intended earofco forsale.ILhowever, deer ill have
Improvement b raid within oseyrarofcompldion,the owner-bit IlderwRl have
t1)9-¢uden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
I,_J L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contactors to corutmet the project(Sm.70K Business and Professbm Code: PERMITLSUANCE � q � E p I N
43
The Contradofd s License Law does raapply to an owner of property who ALTER-DRAIN&VENT-WATER&.NN
builds or Improves thereon, and who contracts for such pkojects with • S Y
coff, M clor(s)Ilarupursuant to the Contradors License Law. BACK FLOW PROTECT.DEVICE
I_J I am exempt under Sec. B&P C for this reason
Owner Date DRAINS FLOOR RODF,AREA,GOND. SANITAY�2, r ��yV
WOR KMAN COMP ENSATION DECLA RATIONFIXTSPER,IRAP BAT
FQF�'Fil
Of hereby ef(irm�that I have a mrti0ote of consent to sell-Insure,or• RECEIPT M
"I adiflateofWorkere Comperuatioalmumnm or a cedlfird copy themof(Sec. GAS EA.SYSTEM-1 WCI OUTLETS PARK FEE Y N
33W,Lab C3
Policy M RECEIPT M
GAS EA.SYSIE.t-0VEA d(EA)
Co��—��—mppppppany -' BUILDING DIVISION FEES
�Cenified copy b filed
the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCI-IECKP•E/--pi
«�1�g
Certified copy b heed y fi the city Ivptttian division.
CERTIFICATE OF EKEMPITON FROM WORK ERS' CRF-ASETRAP PA__ (
COMPENSATION INSURANCEcoca
TThissedionneed not becompleted ifthepermit bforom hundreddollam SEVER-SAMTARY-STORM EA.2WF1'.
(fl W)orless0 WATER HEATER W/VENT/ELECTR C•N(.R�S •E Y
I certify that in the performance o(thewwk for which this permit is heated,
1 shall not employ any person in any manner an as to become subject to the WATER SYSIGf/TREATING 1L
Workees'Compensation Laws of California.Date PAID
-
z Z Applicant NEW
Q RESIDENTIAL PLMB. SQ.FT. Date i tic
Z NOTICE TO APPLICANT.ILafter making this Certificate of Exemption,you
.r should become subject to the Workrrs'Compentatlon pnvbloru ofthe Labor TOTAL:
W Code,you most forthwith comply with such provisions orthls perms shall be BU
ILDINC EEC
WICdeemed revoked
1 C CONSTRUCTION LENDING AGENCY SEISM
IC FEE
I hercbya(flrmthat there b a corotnctlon lending agency for the perform TOTAL: ELECTRIC FEE
Z anceof the work(or which this permit b Wued(Sec.3097,Civ.C.)
U O Iandee.No PLUMBING FEE
LL r Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lani(ythallhavemadthbapplatio..cd•taletluntheaboveirfmccation
1 bcomet.I agree to comply with all cltyand county ordinances and date laws PERMIT ISSUANCE FEES PAID:
7. N relating to building constructor,and hereby authorize representatives of this
city to enter upon the abovo-mentioned property for Inspection purposes. ALTERORADDTOMECH. '
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agalretliabNtkre' d&LAI coal dex nseswhichmayinanywayacerem URHANDIJNCUNH(rOI9,"CFM) SUBTOTAL:
agaWtsal Ci Rhe.orating o(the.patnit
AIR HANDLING UNIT(OVER I0,000CFM3 CONSTRUCTION TAX
-Signature o ppE1
esto/Contlactor I Date O(HAIIST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haardous HEATING UNIT(TO 100,000 BTU) Date t
matedal i s defined by the Cupertino Municipal Code,Chapter 9.12,and the
I Iealth and Safety Code Sedion 25532(a)7 HEATING UNIT(OVER 100,00)BTU) 'I•
❑YeaNo
Wllltheapplkant or ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OIM OR 1 W,0(D BTU)
Yea QNo A
have read the locatrocus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTI!)
the California Health&Safety Code,Sections 25505,25533 and 25536.I 4'
u edemas rad that if the be llding does not cormetly,have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the requirrmenis which most be met 1�'d'1 2•S
prior to Wuance of a Certificate of Occupancy.
R
Owner or aulharized agent - Date TOTAL: ISUEDB 11
OFFICE COPY