19716 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PeWcd Identification PERMIT NO.
Be nRAddress:(03 � TOE.: � -5 1� 1 J 11 .6 /Z
ears ` Phone:
cN CITY OF CUPERTINO-BUILDING DIVISION 2_() _6 Q
Lic.Mon. APPLICATION / PERMIT
BULDIELRICAPLUMBINGHACAL CATEGORY CONTROL.
��nett glneer: Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
' (hereby aHirmtlat lam licensed under provisions o(Chapler9(comnene- APPLIANCES-RESIDENTIAL JOB DFSCRBs]TON
ingwith Section7(%18)of Dlvipon3 ofthe Busivssand ProfesslonsCode,and my
licenr is In(u f. dd(xt. gni / PANELS
L=
Gla Lk.s V
Date Contractor •&Z UP TO 200ANIPS
ARCHITECTS DECLARATION 211-1000 AMPS
02 l understand my place shall be used as public records. OVERI000AMP5 SQFT.FLOORAR /SQ.FL
CO
�u Licensed Professional SIGNS ELECTRICAL'
�< OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MI!C
lawforthe
�Q., (hereby a(firmthatlam exem)rt(romthe CaMrattor's Limnm
C2 following reason.(Section 7031.5,Business and Professions Code:Any city or TEMP.MEM OR POLE INST. -
�g countywhlch rcquimsa permlttococetmct,alter,improve,demolish,creeper
anystruaure priortoib issuance,also requireslhe applicant forsuch permit to POWER DEVICES
file a dgred Merchant that he is licensed pursuant to the provisions of the
3w� Conlrattors License Law(Chapter9(commencing with Section 7000).(Divi- SWIMMING POOL ELECTRIC VALUATI9N
O stoo3 of the Buslneasand Profession Code)or the he bexempt therefromand (7 s O v
the basis for the alleged exemption. Any violation of Section 70115 by any OUILETSSWIT'CHESFIXTURES O D
O applicant fora permit the applicant to a civil penalty of not mere than
$ five hundred dollars($500).
NEW RESIDENTIAL ELECTR SQ. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or m y employees with wages as their sole
compensation,willdotM work and thestrutture is wt intended or offered for
U 0
see(Sec.70K Business and Professions Code:The Contraaors License Law
S$ does not apply to an owner of property who Wilds or Improves thereon,and ROf1Ia RES.IINRS
66 who doessuch work himself or through hisown employees,provided that such
Improvements are not intended oroffered forsale.If,however,lhebuilding or TOTAL:
improvement bsold withlnoneyearofcompldbn,theowner-builderwillhave
t Men of proving that he did not build or improve for purpose ofule.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
U I,as owner of the property,am exclusively contracting with limned PERMIT.ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractors License Taw does not apply to an owner of property who
Wild. ALTER-DRAIN&VENT--WATER(FA)
or improves thereon,and who contracts for such ptpjewith a FEE SUMM
ARY
OUTSIDE FEES
RYc (0lised cenpursuant to the Contractors Lt...Law.m exempt under Sec B k P C for this reason BACK ROW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data RECEIPT
WORKMAN COMPENSATION DECLARATIONFIX.URES.PER TRAP SCHOOL TAX Y_ N
I hereby affirm that I have certificate of conxnt to solfdrsore,ora RECEfi'T M
Ilcate of Worken'Compewtlonlnsurance oracertifled copy thereof(Seco GAS EA.SYST'EM-I INCAOIIILETS PARK FEE Y 'N
3800,Lab Cj RECEIPT N
Policy Y GAS EA.SYSTEM-0VER 4(EA) BUILDING DIVISION FEES
�m any
Certified copy is hereby furnished. GREASE/INDUSCIIL WASE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS• GREASE TRAP PAID
COMPENSATION INSURANCE SETVF.R-SAM.T.ARY-y1DRM E.A.1(110;1• Date Recef l#
('fhissettion need fiat be completed if the pemnit Is for uv hundred dollen
($10(fiorlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I cartify that in the performance ofthe work for which this permit is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z Z Applicant NEW RF9DENTIAL PLMB. SQ.FT. Date Recei t#
Z NOTICE TO APPLICANT-.If,after mak!ng this Certificate of Exemption,you
2 should become subject to the Workers'Compensation provision of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE .0
> deemed revoked
W —
CONSTRUCTION LENDING AGENCY SEISMIC FEE -
IL Ihembyeftrenthatthembaconstmcdon lending agency for the perform TOTAL, ELECTRIC FEE
7 Z an.of the work(or which this permit Is kwed(Sec.3097,CIv.C.) PLUMBING FEE
(� 0 Landers Name
LL H Lendersaddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedlfythel have madthlsapplkatlonand statelhatthe above information FEES PAID:
6. bcorrect.l egreelo complywith all city and county ordinances and pate laws PERMIT ISSUANCE '
} N relating to Wilding construction,and hereby authotlu representatives ofthls
r city to enter upon the above-neentioned property for inspection purposes. ALTER OR ADDED MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V against habilltim,ydgnemus,cops andaxpenseswhlch may In snywaysecrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
fist Bald City In conseque .(the a ruing of this permit.
MAIL--
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
agna mof Applicant onrattor Date EX.-ST IdODD(W/DUCn CONSTRUCTION TAX PATI):
HAZARDOUSMA IALSDISCLOSURE
Will the applicant orfuture building occupant store or handle havrdous HEATING UNIT CIO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 91$and the -
IlcaBhend SafetyCader�-S�ectim25531(a)7 HEATING UNIT(OVER 100,0(10 BTU) TOTAL: rS7
❑Yrs II N.
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamlvnb as defined by the Bay Area Air FAME)
Management District? BOILER-COMP OHP OR 100,0D BTU)
Yes ❑❑ rn
No p(�
4havehead the bazardousmaterials mquireentsunder Chapter 6.95of BOILER-COMP(OVER100,000 BTU) O Q 197V
the Gllfemta Health&Safety Code,section 15505,25533 and 2553x.1 ` cox' H
understand that lithe building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which most be met qtprior to issuance ofd Certificate o(Ompanry. oak�(If bon IDI(
Owneror authorlved agent Date TOTAL: ISSUEDBY:
OFFICE COPY