24749 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO B ILDING-ELEC'RICAL PERMIT NO.
APPLICATION/PERMIT PLUMBING-MECHANICAL n
BUILDING DIVISION BUILDING.PROJECTIDENTIFICATION L 4749
BUILDING ADDRESS. - SANTI'ARYNO. APPLICAT]ONSUBMITTALDATE
6 (
UNIT# OT# �/�
OWNERS NAM' P NE: COM'ROR'S�hfE: LIC NO: ••/
W N/C CONTROLp
ARCHITECT/F.N(i1NEER: LIC NO: AU KESS: ❑
CONTACT: PHONE:
QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
PERMITISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL EOR OFSCRI ION
omz Ihereby affirm that am licensed under provisions nfChapser9(commencing with
lcl Section 7000)ol'Division 3 mitts,Business and Professions Cade,and my liecowls in PANELSUit
full force and effect.
,W License Claes Lic.# UP T0200AMPS
y6y Dam Comramor 201-1000 AMPS / �p
ZOyz _ ARCIII'IECTS DECLARATION OVER 10010 AMPS L E 6./-OOTIKI $/SQ.Ff.
O z_❑ 1 understand my plain shall be used as public records. 911VV��
F,rn Fu: SIGNS ELECTRICAL
Q Y 5 j Licensed Professional
Cm
fac6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC.
O y an 1 nghereby as alt(Se that 1 um exempt linin the Contractors e:Any
Law for the
W 3 y following rear'..(Section N13 LS,Business and Professions dear ns Code:Any city or county TEMP.METER OR POLE INST. 1 .
F a O which"Tors'.permit ro wnxwcr,cher,improve,demolisM1,or repair any structure
� e'�> mics issuance.alsore thea lieam(..such tin files signedvatement POWER DEVICES
1' prior ,aims pp pcmti that he is lia.nsal pureuenl to the provLinns of tM1C Contractors License Law(Chapter SWIMMING POOL ELECTRIC
a�c4 9(commencing with Section 70010)of Division 3 ofthe Business and Professions Code) VALUA'f�1{
�
uKl-w or that he is exempt therefrom and the basis for the alleged exemption.Any violation of OUTLETS-SWITCHES-FlXTURFS w�r/f,
F Z¢ Section]031.5 by any applicant for a Permit subjema the applicant to a civil Penalty of l Do c
iso all -than five hundrcdd.11ars($50(). NEW RESIDENTIAL BLECfR _SQ.FT. STORIES TYPE CONS'I'RUCfION
WI= I,asownentfthepropeny,or my employees with wages astheir sole compensmiuq
a3— sail -the work,andtheswcture ismtimmndMoroffcrM fasale(Scc.]Oa4,Busin<es
and feast...Cale:The Co useare.License law dues a.t apply to an owner of
property ho builds orimproves thereon,andwhodues such workbimselforthroughhis OCC.GROUT' RES.UNITS
.wn employeex.prvidM that such improvememx umnot Intended.nrffued forxule.
If,
however,the building or improvement is sold within one yearofecmpletion,the owner- TOTAL:
builder will have the burden of proving that he did not build or improve for purpose.(
sale.).
❑ I,as owner orthepropmy,am exclusively contracting with licensed commGmsm QTY. PLUMBING PERMIT FEE Fl.rOD ZONE APN
construct the project(Sec.7044.Business and Professions Cale:)The Contractor's
License law distinct apply tom ownewPor erry whobuildsmimpFovea thereon,and PERMIT ISSUANCE
who contracts for such projects with a corvacmr(s)licensed pursuantto the Contrecmrs EA gLTER-DRAIN&VENTWATF,R( 11
License Law. - ) FEE SUMMARY
❑ I wn exempt under Sec. ,B&P C for this mason BACK FLOW PRO!ECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Dau DRAINS-FLOOR.ROOF,AREA.GOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION SCHOOLTAX Y N
• c❑ Thereby NTirm thmlhavcacunifcntcof rnnsent tusel[-inwrc,nrncernificute of FIXTURES-PMIRAP RECEIPT#
nc
Workers'Compensation lnsmnemnemified copy thereof(See.3800.Lab C.)which PARK FEE Y N
rs all employee's under this permit GAS-EA,SYSTEM.)INCA OUTLETS RECEIPT#
Policy# BUILDING DIVISION FEES
company GAS-1?A.SYSTEM-OVER 4(EA) PLANCI IECK FEE
❑ Certified copy is hereby famished.
❑ Certified copy is Blvd with the city inspection division. GREASWINDUSTRI.WASTE INTERCEPTOR GRADING IEE
CERTIFICATE OF EXEMPT TON FROM WORKERS' GREASE'I'RAP SOILS FEE
COMPENSA'r10N INSURANCE
(This section need not be completed if the permit is for one hundred dollars($I W) SEWER-SANITARY-STORM HA.200F1'. ENERGY FEE
or less.)
I eciifythat in the performance-fthe work for which this permit is issued,l shall WATER HEATER W/VENT/F.LECTB
not employ any person in any #
m ,n as to become subject to the Workers' PAID
Z Compensation Lawaof California. DaleWATER SYSTEMO HEATING Dam Receipt
Applicant
Z 0 NOTICE TO APPLICAM':If,after making this Certificate of Exemption,yousbould NEW RESIDENTIAL PLMB. SQ.FT. TOTAL:
(q become subject o the Worker s Compensation provisions of the labor Code,you must �1
fovhw ith comply with meh provisions or this pewit shall be deemed revoked. BUILDING FEE
Ixl Y
4 �
CONSTRUCTION LENDING AGENCY SEISMIC PRE �
I hereby affirm that there is a conswction lending agency for the feel anan.of
V O the work for which this ryrntit is issued(Sec.3197,Civ.C.) 'TOTAL: ELECTRIC FEE
Leader's Name
Lender's Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
U 1 certify thin I have read this application and some that the above information is MECHANICAL FEE
.>- W correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE
I-' n' building coman.Gon,and hereby uuthorim repmsemmivesofthi.s city to enter rear Me
U Z "Moe-mentioned rt for ins .inn ALTER OR ADD TO MECI I.
CONSTRUCTION
props y pec puryoses.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liubilities,judgmenm,costs andexpensex hie may many way twerueagainat rid City AIR HANDLING UNIT(TO IB.000CFM)
nreyucnwo M1e gramin AIR HANDLING UNIT(OVER I0,000 CFM)
it Sirest or pplicanUConvactor Oatc EXHAUST HOOD(W/DUCT) PAID
HAZARDOUS MA'I'ERIAL$DISCLOSURE HEA'PING UNIT(TO 100,000 BTU), Date Receipt#
Will the applicant or future building occupant store or handle M1arrdous material
as defined by the Cupertino Municipal CMC Chaper 9.12.and the Health and Safety HEATING UNIT(OVER 100.000 BTU) TOTAL:
Code,Secri 25255320)?El yes 11 No VENTILATION FAN(SINGLE RISID) i.
❑
ISSUANCE DATE
Will the applicmtorfumm buildingescupant usecquipmentordeviscwhi.Goait BOILER-COMP(3HP OR IIXI,f1(10 BTU)
h:mvdous air comami.mts as defined by the Ray Area Air Quality Mmngement BOILER-COMP(OVER 100,000 BTU) PAID
ULWcB
❑Yes ❑No NF.W RESIDENI'IA1,MECH. SQ.F1'.
I have read the hummous materials r emoomems under Chapter 6.95 of the FEB 8 1qD^
California Health&Safety Code,Sections 25505.25533 and 25534. 1 understand that y
if the building does not currently have it tenmL thin it is on,responsibility m notify the
oecupmt of the repairso enu which must bc met pn.r to issuance of a Certificam of CATV
OccuPancy.
Owner m amborized aper Dam 'f0I'AL: ISSUEU BY:
OFFICE