20140 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmiert Identification '� 1 �s PERMIT NO,
BuBdlpg Addma L/ 20140
�s one:
W- CITY OF CUPERTTN0.BUILDING DIVISION ^�
centra ,Na a: uc.Ne APPLICATION /PERMIT ^t L_�b
'Mw ^^- - BUR.DINGELECTRICAL-PLUMBING.MECHAMCAL CATEGORY CONTROL#
/�
Arc ltect/Engnee. v �
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Sil6-�pSQ
Address: '� . PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DBCLA TION
Ihereby affirmthat l am licensed under provisions dfChapter 9(cormmenc APPLIANCESRESIDENIIAL JOB DESCRIPTION
ingwlth Section 7000)ol Dlvision3 ofthe Busia,sand ProlemioreCode,and m
license lelnfull lance and died. PANELS
License Claes Liep
Datc.Coammiter. UPTO 200 AMPS
ARCHITECT'S DECLARATION 20110DOAMP
�q!NO Zp I understand my plane shall be used as public records. OVERIODDAMPS SQ.Fr.FLOOR AREA S/SQ.Fr.
Ely�j L(ansed Profemiorul SICNSELECTRICA IN
EL�W OWNER-BUILDER DECLARATION SI+ECTAL CIRCUIT w
X. 4 thereby affirm that!am exempt from the Contractors License Law for the i`{(
fo0owing reason.(Section 70715,Business and Proleelona Code:An d or
FEIi"' cauntywhichroqulaeapermittomm tmo,alter,lmpmve,demolieh,orrepair P.MEIPR OR O
a anysttucture priorto its lemance,also requlrestheappllcam lorsuch permit to ppµrEg DEVICES
U file a signed statement that he Is licensed pursuant to the provblons of the DATE
Gw Contractors License Law(Chapler 9(commencing with Section 7000)of Dlvl- '
sift
SOS slon3o(the0uelnemendPMe®IonsCode)orthat SWIMMING POOL ELECTRIC !VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 rcby any OUTLETSSWITCFIESI7 /_OQ ,
applicant fora permit subjects the applicant to a civil penalty of nor othan V
O five hundred dollars(5500).
I,as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT.
❑ p pray,or my employees is with wages as thele sate SIORl6 TYPE CONSTRUCTION
compenea ion,0K will do the Business and k,and the s CodurchrContracded Livens Law
dod for
sale(See.70K to Business of propeProfessionrty
who The
or
License Law
$
doesActapply roan owner ofp rough who Wildsor Improvesthereoryand OCC.GROUP RES.UNITS
who doesents amrkhimself edorwgh hlsowne.If,ho , provided that such
Improvementsarena Intended arrofco forsale.I(howevepthe build
,wilingor TOTAL:
Improverrcnt bmW wllhinoaycarofcompldlorythe owner-bullderwlll bve
tlil,tiurden of proving that he did not build or improve for purpose ofsaleJ. QTY. PLUMBIN PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with Ilcensed PERMITISSUANCE
matradon to constructthe project(Sec.7m64,Business and ProfessionsCode:
The Contractor',Limner Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilde or)�9p n thereon, and who contracts fn such PUod -
je
s with s FEE SUMMARY
cgpf(gp�Ni Ilse Used Punu Contractors License Law, BACK FLOW PROTECT.DEVICE
�( exe pt unci ec. B&P fort b... OUTSIDE FITS
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
Owns ATIO _C RECEIPT N
WO KMAN COMP' ATION feassa A ON FIXTURES-PER TRAP SCHOOLTAX Y N
❑I hereby af/hm that I have o duranc of consent m opytheurc,ora RECEIPT N
cedifiL.b C.) orkers Compewtlonlmuranremra redilled copy thereo((Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARK FEE Y N
350Q Ub C.)
policy p GAF.EA.SYSTEM-OVER 6(FA) RECEIPT N
Co������mppppppany BUILDING OI VISION FEES
LCertified copy b hercbyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V(Ilea with the tlty Inspection dlvlelan.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA 2DWr DB[C Recei t#
RMW
hlaslon need not completed If the permit V(Drone hundred dollars
(5100)nless) WATER HEATER W/MINT/ELECTR ENERGY FEE Y N
l cedll employ
n any person i any a neer so n to became
penult is blued, —
I shall not employ any person In any manner at u to become eubjM to 1M WATER SYSIRM/TREATING
Worlica Compensation laws of California.Date PAID
O Z ApplicNOTICEt NEW RESIDENTIAL PLMB.
Z O NDHGEcome subject
to the orksm'kompensation Procate o(ExempteLothoion,you c�Q FG Date TA t#
I" C d., becorrc af.nhwie the plyk s'Compensatlo..rth pnso teLabor TOTAL:
Uj N Cade,you mkd fmrhwlth comply with such provhlons orthh permltshall be
7 deemed revoked. BUILDING W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a C lherebyelfl tthem B a constadianlendingagcnryfor the perform-
a. Z anre nnne wee *hic this p r`cie. Fa tree �Ig7�W.C.) TOTAL: ELECTRIC FEE
U O 1<naere Nan.c_ i�-`� PLUMBING FEE
Iy H enaer.A...A-- caw QTY. MECHANICAL PERMIT FEE MECFIANICALFEE
O W I cart By that I Wave Hisapphcatlooand&ate that theabove Information
300m
ad.bd.I agree to comply with all cltyand county aNlnanres and Yate laws PERMIT ISSUANCE FEES PAID:
>. N relating to building mnswctlon,and hereby authorize representatives ofthie
H Z cityto enter upon the above-mentioned Property for Wpeetlon purposes, ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino DB[e Receipt#
V against liabilities,judgments,cases end expenses which may in anywayaccrue AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL'
against said City in consequ ens of the granting of this Permit.
AIR HANDLING UNIT(OVER I BODO CrM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EYHAUSr I IOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcant or future building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Revel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the /
Iialih and Safety Cod25532(a)7 }(EATING UNIT(OVER 100,000 BTU) TOTAL: as0.
❑Yea No
Will the applicant oITauIr tore bullding.pant useequlprrent ordevicea VFNIILATION FAN(SINGLERESID) Ir 3p(B DAA
which emit havardoua AIr conbmianb as defined by the Bay Arca Air
Quality Management Dls BOILER-COMP OFNOR100,000 BTU)
Yin, No R z �y
thehazaousmatedalsmquimrnentsunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) Qj
CaIllomi HealthlcSafety Code,Sedbns75505,75573 and 25536. 1
understand t Rthebullcing doe,not corrently have a tenant,that It is my NEW RESIDENTIAL MECFI. SQ.FT. �s;` �^
responslb ylonatllyl atoftherequlrements[hichrwstbemet Rik clip sF.po
rlOr to uance Dict di(lateo Ocmpanry. ItI\I� T'"'a-ML.
Owns authodmilagent / ` e ISSUED OY: 7��L
TOTAL:
OFFICE COPY