23153 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PELMITNO.
But in Ada rest: - . - 23153
ame one it
s A AA(o _ y CITY OF CUPERTINO-BUILDING DIVISION
Contrmhar'a Name: ic.Nn: APPLICATION /PERMIT .�^1 2
OI O BU(LDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL N
Rm/Engineer.• LIc.No:
QTY ELECTRICPERMIT FEE BUILDINGTERMITINFO -
Address PERMIT CES-R CE Ty ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ectionaffirm MOD)hat of
Division
oftheerprwbnd.Pro ions Chapter ssions9de,and c APPLIANCES-RESIDENTIAL JOB DESC ON
Ing with in Section Division3 olthe Business andProfeaslonsCnde,and mylicR,
DII Cs�CLIm C. der _G's .•I 1 PANELS
1 UP TO 200ANIPS
ARCHITECT'S DECLARATION 4 201-IOW AMPS
ce Z I understand my plans shall be used as public records OVER 1(X10 AMPS .FT. R AREA $/SQ.FT.
Ego�qDG I N
I"j Licensed ProfessWral SIGNS ELECTRICAL g L E D
<N OWNER-BUILDER DECLARATION SPECIALCIRCUIT/ML9C (�
F, Thereby affirm that Is.-BUIL ER the Contractors License law for the R
Z OO y following reason.(Section 7031.5,Businem and Pro(esslona Code:Any city or
Pmqq countywhichrequimsaper ttomn mt,alter,impmvpdem lLLh,orrepair TEMP.METER OR TOLE INST. I
Q�Q.a anystmi ieprlortoibimance,aLwrequimtheapphantforauchper tto POWER DEVICES
E, file a signed statement that he b licensed pursuant to the provuhma of the DAT
f
�ppg5 Contractors License (ChapterLaw 9(commencin with Section 7000)of Divi- VALUATION
sion3 ofthe Buslnessand ProfeiomCode)orthatthelsexem therefmmand SWIMMING POOL ELECTRIC
i7 the barb for the alleged exemption. Any violation of penalty
7071.5 by any OUTLETS-SWITCHES m
�O
applicant fora permit subjectstheappllcam too civil pevlty of not more than .J a
c five hundred dollars($SM. NEW RESIDENTIAL ELECTR FT.
),as owner of the roe `SQ' STORIES TYPE CONSTRUCTION
?G Property,ky,9r my employees with wages r ffelr sole
compensation,B.MemtheworkaPretensions Code: bnotintended orofferedfor
S ❑
sole(Sec.apply
to alnows.owner
of property
Code:The uilds or impravesthemer License Taw
dos notapplyvark owner ofp rough who nemporimpmovided that
OCCGROUP RES.UNITS -
whodocasuchwork himselorthrough hisownemployees,provided that such
Improvements are not intended oroffered for sale.U however,thebuilding or TOTAL:
improvement is sold within oneyearefcompletlon,the ownecinulderwill have
todes of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT F'EE
Ityl,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCE
contractors to construct the project(See 7044,Businea and Pro(essWm Code: �. -
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or Improves thereon,and who contracts for such ptnjects with a ,ec FEE SUMMARY -
C061etor(s)licensed pursuant to the Contracture License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under SB&P C for this reasonOUTSIDE FEES
Owner Date
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
RECEIPT N
. WORKMAN COMPENSATION DECLARATIONFIXTURJESPFR?ROIs SCHOOL TAX Y_ N_
�- ❑[hereby affirm that I have a certificate of consent to self-insure,or a �^ RECEIPT p
artificateofWorkers'Compewtionlrnumnceoraceni(led copythemof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
RIKEEPT
38W,�ab C.I G
POI1ryN .$f7I737$ BUILDING
GAS EA.SYSTEM-MER 4(EA)
Cnm ansa ion G G( r MG2.MCG BUILDING DIVISION FF.B$
[�Certlfed copy is heed with the cit: CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified ropy f-9 HIM with the city IrepMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE 5EWER-SANITARY-STORM EA.200ET. Date Rtt I' t#
(Thlssection need not be completed lithe permit is insure hundred dollars
($100)orlcx.) WATER I-[FATEIt w/vFNT/ELECTR ENERGY FEE Y_ N_
I certify that In the per(ormanm of the work for which this permit is blued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Waken'Compenaation Gws o/GBfornb. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
Z O NOTICETO APPLICANT.,after making this Certificate of Exemption,you
should became subject to the Workers'Compenation provbiom of the Labor TOTAL:
N Cade,you most forthwith comply with such provbiom orthb permit shall be BUILQING FEE
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a construction lendiagagency forthe perform T ELECTRIC FEE
Z ante of the work for which that permit Is Issued(Ser.3097,Civ.C.)
(,) O Lender•.Noma PLUMBING FEE
[.enders m
Aaaa QTY. - MECHANICAL PERMIT FEE
LL
U 1urtlfythat l have read this appliationand state that the above Information MECHANICAL FEE
O W is cermet l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building construction,and hereby authorize representatives ofthls
Fcirytoenterupon the above-mentioned property for Wpe tion purposes. ALTERORADDTOMECH.
Z' (We)agree to save,indemnify and keep harmless the City of Cupertino Date Receipt#
V ag.i tlU ' t nts, tend expenses which may in any Y. AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL: `
a irate itytr nse{ ce the Us tingefthls\rmB/ AIRHANDLINGUNW(OVFRIQWOCI'd1 CONSTRUCTION TAX
6
Bottom of Appli nt/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCFION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuwm building occupant store or handle hazardous HFATIN ,UMTtTO1W,WOBN) Date Reeei t#
material as defined by the Cupertino Municipal Coag Chapter 9.17,and the -
liealth.M Safery Code Sectlon2S532(a)? HEATING t)' IT(OVER 100,000BTU) IOTA
❑ Yes M No
Will the applicant or future building occupant use equipment or devices VENILATION PAN QINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
` Quality Management District? BOILER-COMP PTR'OR 100,000 BTU) PAI
FH Yes .us /9 1
sae read the hazy ous materials requirements under Chapter 6.95 of BOIL ER-COMP(OVER 1W,1100BN)
the California Health&Safety Code,Sections 25505,75533 and 75534. 1
understand that lithe Wilding does net currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FE JAN U2 1�aL l
responsibility to notify the occupant of the requirements which must be met /
prlortabsuana MaCemilegeo(oeeupaney. "
CITY uvv
�� l I
Owner or authorized agent Data - ISSUEDB
TOTAL:
OFFICE COPY