19912 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
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CITY OF CUPERTINO-BUILDING DIVISION• 'y� O c° dnr'.Na Lm.N°: APPLICATION /PERMIT t— \
" BUTLDINGELECTRICALMUMBINC-MECFNMCAL CATEGORY CONTROL M
Arohited/En rer. Lk.No:
QTY'`,' ELECTRIC PERMIT FEE. BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ID❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapter9(commenc APPLIANCFSRESIDENTIAL JOB DFSCItD'fION
IngwithSe on70W)°f Divlslon3ofthe Businessand Pmfe msCodgandmy
license le In frcea rad d(ed. PANQS
License /m /�
Date Cantrador �\� � 1.,C 4KJ
ARCHITECTSDECLARATION OVER0000 AM
°�.FL.FLOOR AR 8/ .Fr.
µqqµ!!�20 I understand my glare.hal be used a public records. 1 `.4
E Licensed Professional SIGNS ELECTRICAL -
<6 OWNER-BUILDER DECLARATION
In SPECIALCTRCUIT/MTSC
E, owing raffirmlhallam31.5,B fromthe Contractor's License Gw city he or
countingreason.ir(Section
aprmitto Business and Professions Code:Any cityorTEMP MLTER LE INYT.
p� any-tythkh requires.baus to construct,uagmteh apmvent(ontlsh,or repair
a any atmeture Prior to its heuance,aLsorequlresthe appllunt forsuch permit POWER DL
�a V file a signed statement that he Is licensed pursuant to the provislom of the
0. Contractor's License law(Cha pler9(commencing with Section 7000)of Divi-
SWIMMING E C
F.,� g s�on3ofthe Business and Pna(emiovCode)orthat hsbexemptthere(romand VALUATION
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any //
r�
applicant fora permit subjects the applkant too civil pevity ofnotnnrethan ET' HF& ES 1 N` /rel
�C $
fly, I,as
sro nerofdeltashepr. NE Rrs ENTIA STORMS TYPE CONSTRUCTION
a, ❑I,asownerof theproperty,orhe employee.otwith nwagesrthelesoleIt. JMX
H rompem.7W4,wnuftesthe wwkand thea Cdurehnotlnlended License
for
O sae(Sec. pply to anowandf property
Code:The or improves
Licereelaw
$$
does not
ant such loanowner orpropertywho nemporlmprwvided con
,and OCC.CROUP RES,UNITS
who doensuch work himseRorthwgh Maownemploycea,provided that such
Improvements are not Intended oroffered for sale.If,however,lhebuiiding or TOTAL:
improvement bsold withinoneyearolcompldioMtheowner-budderwlll have
tlnof proving that he did not build or Improve for purpose of sale.). QTY, .,. PLUMBING PERMIT
-tnFEE FLOD07ANE APN
s owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor,to construct the project(Sec.7066,Business and Professions Code:
Tux Contndor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such ptojede with a
, +dor(q licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEESUMMARY
"I am exempt under Sec, B &P C for this reason
DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY- Y N
. Owner Date - RECEIPT R
WORKMAN COMPENSATION wrifi10N DECLARATION FIXTURES PER.TRAP 501001.TAX Y N
❑I hereby affirm that I have• Insurance
of consent to se8-neure,ora RECEIPT It
certificate of Workers'Comperuatlonlvurance ora urtl(Ird copythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polity M^X(.�C.7 r20� / G
T
GAS EM
EA.SYST -OVER6
�^) BUILDDINGING DIVISION IV VISION FEES
Certified py is heed with the
city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified ropy h filed with the city Inspection divisors.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE 71b PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200PT Date Recel t#
(Thhsection need not W mmpldud tithe permit le forone hundred dollars
($100)or less.) WATER HEATER W/VENT/ELGCIR ENERGY FEE Y N
I coe
codify that in the pedamnce of the work corwhich this permit is hated,
I shall nm employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING Workera'Compensatlon Laws of Giltornla.Date PAID
O Z Applicant
Z O NOUCETO APPLICANT:If,after making this Certificate of Exemption,you NEW RFSIDENTTALPLMI,__EQTr. Date RCccl [#
should become subject to the Workers'Compevmion provislom of the Labor TOTAL:
Cr
X� Cade,you muetfarthwlth comply with each provLsloru orlhh pemNt shall be O
deemed revoked,
BUILDING IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE ^a
IL G I hereby affirm that there h a construction lending agency for the perform~ ELECTRICFEE
ZanreottheworkforwhichthbperMtlshsued(&c.3097,Civ,Q) TOTAL:
0 O lender's Name PLUMBING FEE
LL 1= Lundce.Address Q'rY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedifythat l havereadthis appliutlon and statethat theabove information
bcorred.l agree to comply with all dlyand countyordlnancesand statel.wa PERMIT ISSUANCE FEES PA
>. y relating to building construction,and herebyauthorize reprexntativea olthb
F Z city to enter upon the above,mcntloned property for irupMe,ion purposes ALTER OR ADD TO MECH, a[e - RCCCt t#
_ (We)agme to save,Indemnify an d keep harmless the City of Cupertino P
seg iabilltles,Pdgmmus,costa expe seswhl maylnanywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
a Ins Id City In con sequ th gr n Is permit.
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
SI tureol Applioni cruad D e M(HAIIS'T HOOD(W/DLICT) CONSTRUCTION TAX PAID:
HATARDOU ATERIALS DISCLOSURE
Will the applicant or future ullding occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Hcalthand Safety CodeSec 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yet [ o
Will the a ppllunt or future building occupant use equ ipment or d evices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hanrdous aft contaminants as defined by the Bay Area Air �D
Quality Management Dislrid7/ BDII.FRCOMP pE1PDR t00,IX10 BTU)
I—I Yrs FCL'atf
0i —havereadthehaa ous mater late requirements under Chapter 6.95 of BOILER-GDMP(QVER 100,000 B7U)
the California Hoalth&Safety Code,Sections 75505,25533 and 75536.1 !1 [?7 3 990
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECTL SQ.FT. APR
res ibllitYin notify theoc p ntofthe yulrements which must be met
or issusncoo(•aaQ'CertiI to I m racy. City, of Cuge[tino
mer orlud age Date �� ��
TOTAL: ISSUEDB
OFFICE COPY