20457 APPLICANT TO FILL IN INFORMATION WITIiIN RED LiNES — USE BALL POINT PEN ONLY
Buildin Pro'ect Identification PF.RMITNO.
8uilding Addtess: Z 0 4 5 7
� I1�P�6 �e � ��
ers ame: hone:
A A
` -�-� �� 7..� f� CITY OF CCTPERTINO-BUILDING DIVISION
Contractor's a�: _ r.+�.cvo: AP P L I CAT10 N / P E R M I T 2
� ��►�� ' � BUILDINGII,ECTRICALPLUMBIIVG-MECHAIdICAL CATEC',ORY CONTROi��
A ted gi r. Lic No: «Z'TQ
—� ,
�;a C � S �T�t ELfiCTRIC PERA4iT FEE BUiLDING PERMIT INFQ
Address: � • • G PERMITISSUANCE � 'U° ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9(commenc- �'1'I.1.4NCFSRESIDENTIAL OB DESC ON
ingwith Section 7000)of Division 3 otthe Business and Professions Code,and my
license is in rce,andeffect.� .��� PATfECS �� �� -�_
Licen CJa
G�/3 t��.a � t �•1l
Dat Contrador 4�":
ARCHITECTS DECLAR TION 201-1000 AMI'S
0 O I un t �ns s all be use�as public remrds. OVER 1000 AMPS SQ.Ff.FI.00R ARFA g/SQ,Ff,
W� 'u�'"� SIGNS ELECTRICAL
�U Li sed Professional � � O � �n P1^
t-•Q� OWNER-BUILDER DECLARATION � �,���F+
�n]m SPECIAL CIItCL1IT/MISC
�., z I hereby affirm that I am exempt from the Coniractor's License Iaw for the
O"�..'`" following reason.(SecHon 7031.5,Business and Professions Code:Any dty or
��.,� TEMP.METIIt OR POLE IIVST. �^�3 � ��
county which requires a permit to construct,alter,improve,demolish,oz repair
��.� anystructurepdortoitsissuance,alsorequirestheapplicantforsuchpermitto ppyygRDEVICES
�V Eile a signed statement that he is licenaed pursuant to the provisions of the
3 k,� Contractoi s License Law(Chapter 9(commencing with Section 7000)of Divi- g��qNG I'OOL II,ECTRIC VALUATION
�¢ sion3oftheBusinessandProfessionsCode)orthatheisexempttherefromand
���7 the basis for the alleged exemption. My violation of Section 7031.5 by any
�¢� applicant for a permit subjects the applicant to a avil penalty of not more than OUTI,ETSSWITCHFSFIXTCJI2FS �� /� (" c��` (�
"b
�o� five hundred dollazs($50�. 9Q,Ff, STOItIES 9 TYPE CONSTRUCTION
�n� NEW RESIDINTIAL ELECTR
,j z� �I,as owner of the pm p e rt y,or m y em plo yees with wa ges as their sole
compensatlon,will do the wor1S,and the struchtm Ls not intended or offered for
�p sale(Sec 7044,Business and Professions Code:The Contractoi s License Law
r3� does not apply to an owner of property who builds or improves thereon,and
� whodoessuchworkhimsefforthroughhisownemployees,providedthatsuch � OCC.GROLJP RFS.LINITS
improvements are not intended oroffered for sale.If,however,the building or TOTpAI.:
improvement is sold within one yearof completion,the owner-bullderwill have
the rden of pmving that he did nM build or'vnprove for purpose of sale.). t3'{']; pLUMBING PE1tMIT � F[,ppD TANE APN
�I,as owner of the pmperty,am exclusively mntracting with licensed PIItMTT ISSUANCE �"
mntractors to mnstrud the project(Sec.7044,Business and Professions Code: s�
The Contrador's Llcense Law does not apply to an owner of property who ��_D 6c VENT-W (FA� _
builds or lmproves thereon,and who contracb for auch p{ojects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractor's License Law. gp�� PROTECT.D •E
❑I am exempt under Sec. B k P C for thia rnason
Owner Date DRAINS IZ.ROOF, � TTp, t SANIT'ARY YR��f�
WORKh1AN COMPENSATION DECLARATION �(.I.URE 1RA? SCHOOL TAX Y N
�TTiereby affirm that I have a certificate of consent to self-insure,or a c�j RECIIP.r w
certificateofWorke:s'CompensaHonInsuranceoracerti(iedrnpytheieof(Sec. G����.� ,jNC.40U'TLEfS PARKFEE Y N
3800,Iab C -.. �? .
Poliry H ���.� �! i GAS EA.SY VER 4(EA) RECEII''f q
Company ` "i- _ . ' - : HUILDINGDIVISIONFEES
ertified co�hereby turnished. GREASE ` usnu,wnsre i� �rox �: PLANCHECK FEE
�.Grri�d copy is flled with the dty inspedion division.
CER'IIFICATE OF EXEMPTION FROM WORKERS' G x r
PAID S�`�� ��$�' [�`
COMPENSATION INSURANCE SEINER_SA�IIT.ARY S1'ORME4 zoo�. Date Recei f# J v�0
(fhis section need not be completed it the permit is for one hundred dollars
($�oo)or lesS.) �,"A.i.��.��f��.l,��� NERGY FEE Y N
I certify that in the performance of the work for which this pemut is issued, � ' — —
I shall not employ any person in any manner so as to become aubjed to the WA��S �T,nEA.nNG � AID ^Z T`�� �M�,,�
Workets'Compensation Laws of California.Date � - ?' �" � `�YY��
; Z Applicant NEW RFSIDFNCIAL PLM �. ,x`x � Date Recei t# ���
� O N01TCE TO APPLICANC:If,afrer making this Certificate of Exemption,you ,�
should become subject to the Workets'Compensatlon provisions of the Labor $ TOTAL:
� � Code,you must forthwith mmply with such provisions or this permit shall be �� BUILDING FEE �
deemed revoked.
V > CONSTRUCTION LINDING AGENCY "'� SEISMIC FEE �
L � I hereby affirm that there is a wnstmdion lending agency for the pedorm- ELECTRIC FEE
� Z ance of the work(or which thLs permit is issued(Sec.3097,Civ.CJ TO L: `
) 0 LendeisName PLUMBINGFEE
L H 1.ender'sAdaress QTY• MECH'�NTCA�-T' �E �HAI�IICAL FEE
' W IcertifythatIhavereadthisapplicarionandstatethattheaboveintormation 1
is mrrect.I agree to comply with all city and county ordinances and state laws ; � I'Q2MTI I � � E � � F E�PAID:
r y relating to building mnstruction,and hereby authorize tepresenWtives of this : �
city to enter upon the above-mentioned property for inspection purposes. O �D
z (We)a g r ee to save,indemni f y an d kee p hamiless the Ci t y of Cu p ertino ` �� � � � ��/� Receipt#
� against liabilities,judgments,costs and expenses which may in anyway accrue ��� �N �(TO 10,000 CFM) SUBTOTAL•
ainst sai ity' coqsequeyce of the�granting of this m,;c. CONSTRUCTION TAX
� G��� I,� � . G (� 10,000C�)
l5i tum of Applicant/Contractor Date UST HOOD(►N/DUC'n CONSTRUCTION TAX PAID:
HAZARDOUS MiRTERIALS DISCIASURE
ill the applicant or future building occupant store or handle hazardous �nNG UMT(TO 100,000 BN) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17„and the
Health and Safety Code Section 25532(a)? HFATING UI�IIT(OVER 100,000 BTLn TOTAL• .
�Yes �No
Will the applicant or future building occvpant use equipment or devices VENITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMI'(3HI'OR 100,000 BT'U)
4 Yes �No �y
have read the haza ous materiaLs requirements under Chapter 6.95 of BOII.ER-COMP(OVER 100,000 BN) f�'"'/�j�'
the California Health&Safety Code,Sections 25505,25533 and 25534.I
unde�tand that if the building does not currently have a tenant,that it is my NEW RFSIDFNIYAL MECH. SQ.FI'. �`:'
responsibility to no[ify the occupant of the requirements which must be met 4=L'�'�� � �j � - _� i
t_.vi,,
prior to issuance of a Certificate of Occvpancy.
Owner or authorized agent Date ISSIJED BY."'`4(J���!
TOTAL:
OFFICE COPY