22038 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'erl Identification PERMITNO.
Building A'drtv,O� 3 : 22038
ams: ``11Phone.
CITY OF CUPERTINO-BUILDING DIVISION
c°n115's�N'me: _r Lic.No: APPLICATION I PERMIT —I J
� /� RUfLDINGELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL#
Archlted/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcsc
LICPERMITISSUANCE El 1:1LICENSED CONTRACTORS �f El
I hereby affirm that l am Vicensed under provIslonsef Chapter 9(mmmen APPLIANCES-RESIDENTIAL,/ JOB DESCRIPTION
It...1.edlon fee.
(the Bucinneandlsro(eseloneCode,and my
Incense is 1.ec full force and affect. PANELS
Lk,axa Class Lic.#_
Date Contractor
ARCHITECTS DECLARATION XF1000 AMTS
90 O I understand my plana shall be used as public rerords OVER IOW SQ .FLOOR S/SQ.Fr.
E� Licensed Pmfesslmul SIGNSEL L
a�6 OWNER-BUILDER DECLARATION SPFCIALC T/MISC
F, I herebyafRrmthat l am exempt from the Contntlor'a LlcenseLaw(erthe p
followln reoson.(Sedlon 7Bfl S,Business end Profenbns Cede:Any city or
OL B I. EITiR OR POLE[NST.
q� county which requlmapermit toco�utrun,alteq lmprove,dennlIsh,or repair
S anystructure prior to Its Issuance,elso requires theappVant for such permit to OWER DEVICES
eJ s Ble a signed atatemenl that M b Ilanacd pursuant 10 the pmWloru of 1h: _
3w Contractors License Law(Chapter 9(commencing with Sed1on7000)0(
Og slon 3 of the Buslnessand Profemloru Code)orthat hebexempt the mand SWIMMING ELECTRIC V` Tlo
�5�p+ the Wab for the alleged ezampll°n. My violalbn of Scctbn IS try any yy Q�
65
applicant fora permit subjedsthe applicant to a civil penalty of not more than UTLETSSWTTCHESEDTEj RES 1(y
A .hundred dolIsre($500. NEWRESIDENIIALELECTR SQFr. STOEFS TYPE CONSTRUCTION
PD. of the property,or my employees with wages as their sole
7a peneatiowon,ner witldo the worksndthestructure Is not Intended or offered for -
q sale(Sec 7016,Bushes.and Professims Code:The Contractors License Law
$ does not apply to an owner of property who Wilds or improves theme,and OCC.CROUP R75.UNITS
who doessuch work himself orthrough his own employees,provided that such
improvements am not Intended oroffered for sale.If,however,thebullding or TOTAL: L
Impmvement ilsold withlnoneyearofcompldloNtheowner-builderwlll have
tiWjlurden of pmving that he did not build or Improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
rontractom to conegruct the project(Sec.7016,Business and Professions Code:
The Contrador's License Law does out apply to an owner of property who ,��-DRAIN VENT-WATER(EAEWilds or fmprovo th etan,and who contracts for such penjects with
onBlTador(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for this reason
QUTSI DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Dale RECEIPT p
WORKMAN COMPENSATION DECLARATION PER.TRAP SCI TAI( Y N
QI hereby afllnn that I have a certificate of consent to self-Insure, FD(TURES
or RECEIPT#
3900,Lab
C.I ao(Worken'Compewatlon ltuunnce ora certified ropy thereof(Bee. GAS F.A.SYSTEM-]INCA OUTLETS PARKFER Y_ N
3800,l
Policy p RECGAS PA.SYSTEM-OVER 6(EA) INGDp
Com any BUILDDING DIVISION FEES
Certified copy Is hereby tum
Certified copy Isfiled with theecity
inspection division. EPCREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
� ly i
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA.SETRAP PAID 1441;-IL �(320
COMPENSATION INSURANCE SEWER- STORM EA.200FE Date ReceI ted --k—
($100)
-k—
(Thlssedionneed not W complded I(Ihc permit Is forone hundred dollar
(fi mutifysa.) le permitWATER HEATER W/VENT/E.FCTR ENERGYFEE Y N
I arson employ
lothe person in olthework forwhichcosesubj Is Bound, —
1 shall not employ any person In any manner so as to become subject to the WA�SYSTEM/TREATING
Worken'Compensation Gwe o(Gllfomla.Date Pplp
O Z NOTICApplIcaE NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t#
Z p NOTICE TO APPLICANT:If,after cooking this Certificate o(Exemption,you
should become subkct to the Workers Comperuation pnwhoom of the Labor TOTAL:
(/J Code,you must forthwith comply with such provisions orthis permit shall be B
> deemed revoked.
a >
a CONSTRUCTION LENDING AGENCY SEISMIC FEE L
IherebyafBrm lhatthereis cowtrudlon lending agency for the perform-
Z once of the work(or which lhislZmdt Is Issued(gee 3097,Civ.Q TOTAL ELECTRIC FEE
O O Lender.Name PLUMBING FEE
LL H Lender's Address QI'Y. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythat l haveread thisappliationand state thattheabove information
(1 Iscom tingreelommp:yw11ha11dtyand countyordlnanmandstatelaws PERMITISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives of(hg
Z city toenle upon the above,memiuned property for inspection purpose. ALTER ORADDTO MECH. Date RefCi H7
Z (We)• to-
i d keep hamdess the City of Cupertino
against Va Vtles,;udg nb,costa• daxp.pw whichnuyinanywaysecme AIR HANDLING UNIT(TO 10,MD CFM) SUBTOTAL:
ago Wt co
gE..rSqkfha granting of this pertnlL(� p AIR HANDLING UNIT(OVER I O,D00 crm) CONSTRUCTION TAX
Igmlu o AppVcant/Contra r J .lel IXINUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZAR SMATERIALS DISCLOSURE
WilleappVartorfuture building occupant store orhandle hazardous HEATING UNIT(TO 100,ODOBTU)
material s defined by the Cupertino Municipal Code,Chapter 9.1$and the Date Reeei t>#_
Hea11h and Safety Code Sedlon 25537(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yea. M No
ill the applicant or future building occupant use equipment or devices VENILATION TAN(SINGLE RESID) IS$UANC[v�
which endl hazardous air contaminants as defined by the Bay Area Air
hty Management DIsMci7 BOILER-COMP OHP OR 100'em BTU) #L a�
4 Ye rl No 4 j!�1s
have read the haze o 0.terials requirements under Chapter 6.95 of SOILER.COMP(OVER 100,000 BTU) el 4d! S ] p�
the California Health&Saf Code,Sections 25505,759 �
3 and 75534.I #a' P 19
understand that if the Wilding doe not currently have a tenant,thatitismy, NEW RESIDENTIAL MECH. SQ.FT.
responsiblllty to notify the occupant of the rcqubcmenlewhich mu at be met
Prior to Issuance of a Certificate of Ocmpaocy. -I
l
Owner or aulhorieed agent Date -'
TOTAL: ISSUEDBY:
OFFICE COPY