19851 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER.MITNO.
Building Addrece,R,rnco Q . - 19851
t_oves, are: V L Phone: p
L DA 11
C 2 't CITY OF CUPERTIN&BUILDINGDVI ON
Contractor's Name: / Le.Na: APPLICATION IPE
Cr' PCrc� BUILDING-ELECTRICMLPLUMBIN MCAL )CATEGORY CONTROL#
�nrch /Engfrieer. Lk.No:
QTY ELECTRI PER BUILDING PERMIT INFO
cid,!% e�IE—SOWN (�1FLR`pp��a p
Address: y/. Sr Sa I'ERFRTISSUANCE IP LU
LICENSED CONTRACTOR' DECLARATION � TLV
I hereby affirm that l am Bernard under provisions of Chapter9(commenc- APPLIANCESRE E J BTAX
ON
ingwith Sectbn7000)of Dlvision3ofthe Busiruresand Professlon,Code,and my �R�license isInfuI forceand affectPANELS
License CBa.C•_-
Dater _#.. 4n Contractor
ARCHITECPSDE "RATION 701-1 OOOAMPS I e
0' I understand my plan shall be used a,public recordw OVER 1000 AMS SQ.FT.FLOOR AREA S/SQ.FT.
O
U Licensed Professional SIGNSELECTRICAL
FA OWNER-BUILDER DECLARATION SPECIALCRCUI7/MLSC
7 s- a I herem by affirthat lam exempt from the Contractor's License Law forthe
K P�y following reason.(Seaton 7011.5,Business and Professions Cade:My city or
A countywhichrequimaper ttomrotrua,alter,impmve,demolbh,orrepalr ER TEMP.METOR POLE INST.
rde`^I' 7 anystua mprlortalb issuance,.LwrqulreatheappBantforsuchpermitto POWER DEVICES
file a signed statement that he t licensed pursuant to the provisions of the
�Oro� Contractor's License Law(Chapter9(commencinwith Sectbn7000)ofDivl-
3 O g
F, ,lona of Business and Professions Code)orehat hetexempt therefrom and SWIs4MING POOL ELECTRIC VALUATION
Sn the basis for the alleged exemption. Any violation of Section 70115 by any D V f7
uulGa appllcantfora permit subjeaathc applicant to a civil penalty of not morethan OUILETSSWH'CI-IFSF[XTUAES a
GSpsR five hundred doll..(SM. NEW RESIDENTIAL ELFGTR
cI,as owner of the property, QFC. STOW TYPE CONSTRUCTION
j..7a O..a non,will do thwrndr�my
is not intend dor offered our
�S^^ sale(Sec.700A Business and Professluns Code:The Cmdraamea Lt..Law
does not apply to an owner of property who Wilds or improves thereon and OCC.GROUP RES.UNITS
who doessuch work himself orthrough his own employees,provided that such _
improvement are not Intended oroffered for sale.If,however,thebuilding er TOTAL:
improvementissold within omyearafcompletioMtheowner-bu0derw111 have
t rden of proving that he did not bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE p(pp w EE APN
I,as owner of the property,am exclusively contracting witho—
contractors
c o— PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profession,Code: 20
The Contractor's License law clan not apply to an owner of property who ALTER-DRAIN&VENT WATER(EM,or Improves thereon,and who and-et, for such p,*U with a
CQB.t.�aaar(s)licensed pursuant to the Contractor's Llrense Law. FEE SUMMARY
LJ 1 am exempt under Sec B k P C for this mann BACK FLOW PROTECT.DEVICE 1
DRAINS FLOOR,ROOF,AREA,GOND. SANITARY Y_ N_Owner Date RECEIPT#
WORKMAN I have.COMPENSATION DECLARATION FDnIJRES PER TRAP SCHOOL TAX Y N_
❑I hereby affbm that I have s ceMnate of consent ro copy
or RECEIPT#
nicersoj.eo(Workera Comperisatlon Insurance orarerti(Ied copy Hereof t$ec. CAS PA SYSTEM-1 INC OUTLETS
3800.Lab CJ PARK FEE Y N
Policy It RECEIT M
Com ny CAS EA.SYSTI2A-0VER4 WA) BUILDING DI V1510:V'FrES
Cc
copy t herbydwith the
cityed. GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
IQ7 Candied copy Ls filed with the city Impealon division.
Y" CERTIFlCATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY
(TEissectlon need not bemmpleted Rine permit oforonehundred dollars STORM EA.200Ff. Date Remi t#
($l OD)orlyth) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
Imrtlfytha performance the performanof the work for which this prmt
clttsaed,
I shall no employ any person In any manner so a to be..subject to the WATER SYSTIM/,TREATING
Workers'Compensation Laws of California.Date
0 PAID
Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RFctDENTIAL PIMB. SQFT. Date Repel t#
should become s.bim to the Workeri Compematlon pmvbiomu of the Labor
N
Code,you=at forthwith comply withaach provisions or this permit shall he TOTAL:
lL > dremrd revoked. BUILDING FEE . 0
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a mretruaion lending agency for the perform- ELECTRIC FEE
7 Z ance of the work for which this permit t Issued(Sec.3097,Civ.C.) TOTAL:
ot,V O Larders Nacre
U. tandcr,Address LLd a QTY. MECHANICAL PERMIT REE PLUMBING FEE
O w Icvnuythatthavrreadtht appuano... matethattheabove lnfamunon MECHANICAL FEE
a tmrretl agree to comply with all city and county ordinances and state laws PFRMTTISSUANCE FEES PAID:
} N relal Ing to Waling commuction,and hereby authorize representatives of this
Z city to enter upon the abovn.mentlonal property for inspection purposes. ALTERORADDTOMECH.
V — (We)agree to save,Indemrdfy an d keep harmless the City of Cupertino Date Receipt#
ago Wt liabilities,y dgment,corns and expenses which may 1.any wayac.us AIR HANDLING UNIT(TO l0,ODO CFM)
.,zonsaldc' m moftheSUBTOTAL:
ae-. granting of thibipermit.— PIR HANDLING UNIT(OVER IQOOOCFM) CONSTRUCTION TAX
Signatons-IMPPlI.ot/Contrsaor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle ha,ardous HEATING UNIT(TO 100,Wo BTU)
maDate
terul a,defined by the Cupertino Municipal Code,Chapter 9.12 and the R2Cej t#
I❑ah and Safety Code ScNioon 25537(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL'
J
Will the hataousa ore Wildingoccupantdeft nd by the Bay Area devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardom air mora Mnants a,delined by the Bay Area Air /�g
Quality Mawgemcat District? BOILER-COMP PHP OR 100,000 BTU) FCBD®
4Yea I�No
havereadthe haza}'�ousmatefl.6mquircmenhunderChapter6.95of BOILERCOMP(OVER 100,000BIU)
the California Health A Safety Code,Sections 25505,25533 and 25534.1
understandthatifthe Wildie8does not comently have a tenant,that it is my NEWRFSIDENTIALMECH. SQ.FT.
responsibility to notify the occupant of the requirements which must hemet �s
prior to issuance ofd Ca;ry(I Ompanry� CitV of rnnP
,r]/ /' /i//�/ rtin�
Owner or authonzed ag Data I
TOTAL: ISSUED BY:_
OFFICE COPY J