20778 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNfO. 7 7
Building Address: O 1 1 S
O 5 ti2t �I E G .
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1'41": �� CITY OP CUPERTINO-BUILDING ntDIVISION -7 _
Coragpraga a LIN APPLICATION /PERMIT ( —
^4 BUILDINGELECTRICALML BING-MEC}IpMCAL CATEGORY CONTROL#//
Ar n/ neer.)KI- ' �Lle'Nn' QTY ELECTRIC PERMIT FEE Ip/
L BUILDING PER INFO
Address: I I PERhRTI55UANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby a(fimntha(lamllemsed under provisions ofChapter9(comment APIsIJANC7SRFSTDENTIAL - JOB DEiiceTI 'ION
ilawn1Section foreesod afflon3o(theBuelncssand Profession.Code,and my
license 1.In full form end e((et. PANELS
License Class Lie# _ 5
1 Date Conentor UP TO 200ANU!S
ARCHITECI•S DECLARATION 701-1000AMPS
fl$ [understand neyplanushallbeused aspublicomords. OVER1000"I'S SQ,FT.FLOOR AREA $/SQ.FF.
O
Licensed Professional SIGNSELECTRICAL
1 OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MISE
2f, owing reason.
thatIs.7exempt from the d Proltorb License Law fort he
oo qq followingreason.(Section70115, o Businessandand Professions Code: it D
FZq csuntywhlch requlresaperMtrocorutmn,alteg improve,dennl0h,orrcpair '[EMP.METERORI'OLEINST
X77 acystmMm prior to its Issuance,alsomquiresthe applicant for such permit to
provisions of DEVICES
file a signed statement that he is licensed pursuant to the provisloof the '
Oµ Contractor's License Law(Chapter 9(commSWR.IMING IDOL E7.ECIWC
encing with Section 7000)of Dist. rT VALUATION
SOS slon3afthe Business and Prole®lamCode)mthat he 6 ameepttherefromand
the Ws6 for the alleged exemption. Any violation of Section 7031.5 by any D «.rrJ�
6 5 OI77LETSSWITCH[SHXTURFS
five hundred
a permit applicant to a dull penalty d not more than
'µ (iE]1,as owner of the property,
NEW RESIDENTIAL ELECTR
�Laaoon,wal oche wcerty,ormyemtum,1.s with nInten ed r offir ered
for TYPE CONSTRUCTION
0
compensation,wRiress.nd PnofdthesWae:TheC graded Umnse Law
$ O sale(Sec.7614,Bueinesaand Profeaslore Code:The Contractor's Llcerue law
5$ does nW.pply to an owner of property who builds or improves thereon.and OCC.GROUP RIS.UMTS
who does such work himself or through his own employees,provided that such
Improvements are not Intended oroHered for sale.If,however,the building or TOTAL:
Improvement is sold within oneyearofcompinion,the owner-buflderwlll have
the*rden of proving that he did not build or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L ate owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contmdom to construct the project(Sec.7044,Business and Professions Code:
The Contractors License Law dam nat apply to an owner of property who ALTER-DRAIN&VENT-WATER[EA)
Wilds or Imprwes thereon,and who contracts for such pn
(ojan with a
ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LJ I am exempt under See. B&P C for this reason
DRAINSFLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECIRPT It
WORKMAN COMPENSATION DECLARATION pD(.pQgEs pg[q T)tpp $CIi00L TAX Y N
❑I hereby affirm that I have a certificate of consent to self-insure,ora RECEB N#
uelflateofWorkem'Compemationlmuranmora mrdited mpythemo((See. GAS EA.SYSTEM-1 INC.4OUTLETS PARK IEE Y N
MOD,Lb C.I
Policy - CAS.FA.SYSTEM-0VER4(EA) RECEfPT#
Com any BUILDING DIVISION FEES
�Certl6ed ropy b filedbarewith
the cid. GREASE/INDU5ML WASTE INTERCEPTOR PLANCHECK FEE (• .Q3
Certified copy k([led with the city Inspersion dlvlelon.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SNftM EA 7WF1. Date Recti t#
Ihle centers need nm W completed If the permit V Carom hundred dollars
($100orleas.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work forwhich this permit Is Issued,
I shall not employ any person in any manner w an to become subject to the WTI,
Workerc'Compensatlon Law.of California.Date A102 SYSIITI/TREATING PAIDgl?J
0 Z Applicant
Z Q NOTICE TO APPLICANT:If,after mild ag this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recel t# Q
should become subject to the Workers'Comperua(lon provisions of the Labor TOTAL:
CCN Code,you must forthwith comply with such provisions or this permit shall be Z
y deemed invoked. -
BUILDING FEE O
W g CONSTRUCTION LENDING AGENCY _ SEISMIC FEE
CL I hcmby a(Brm that them is a comtmctlon lending agency for the perform ELECTRIC FEE
7 Z ante of the workfor which this pemdt I.Wued(Sec.3097,Civ.C.) TOTAL:
(,) O Lender'.Name juNu
PLUMBING FEE
LL F Lender's Address QTY. CAL PERMIT FEE MECHANICAL FEE
OW 1 certifythat I have read this application and dt tethattheoboveleformatlon
a is cormt.I xgma to comply with all dtyand countyordlnanmsand nate laws PERMFEES I
} N relating to Wilding construction,and herebyauthorlurepresentativesafthis (—L-��l
� Z city to enter upon the above-mentioned propertyfor Wpenlonpurposea. ALTEMECH.
(We)agree to save,Indemnify an d keep harMess the City of Cupertino Date Receipt#
V against liabilities,judgments,mrtsand expenses which may In any way accrue AIR HT IO 10,000Ef SUBTOTAL: -de
agauatsaid City in comequenceof the granting of this permit. -
AIRIIIT(OVER10,00 IM) CONSTRUCTION TAX
Signature of AppRant/Contractor Date IXHA /DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllant or future building occupant store or handle haeardous HEAT100,000BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.I$and the Date Reeei t#
I Iealthand SafetyCode Setlon75537(a)7 HEATING UNIT(OVER 100,1100 BTU) TOTAL: (��•#
F1 Yes M No
Wtlltheappllcant or future Wilding occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) I$BU.#>,�DATE
which cent harardous air contaminants as de0aed by the Bay Area Air rN�y
Quality Ma mgement Dist ri t7 BOILFR-COMP OHP OR 100,"BTU) -
❑
yea ❑No JAN
,a
Ihavef. the 6 Is Safes materials nder of BOILER-COMP(OVLR 100,f1(pRN)
the California health&Safety Code,Sea lone?5505.25573 and 75536.1
understa ad that if the Wilding doe.not currently have a tenant,that it is my NEW RRSIDFNIIAL MEIN. SQ.Fr.
responsibility to notify the occupant of the requirements which must be omq —
prior to Issuance of a Certificate of Oavpancy. 0,ot
Owner orreuthorired.Sam Date ISSUED BY:
TOTAL:
OFFICE COPY