20608 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
BuildingProject Identification PUNT NO,
Building Add res.:
�IsH3 Pl e. CY 973-sf33 ` 20608
one: A A
CITY OF CUPERT[NO-BUILDING DIVISION /'
L DAFE
>,10Cortractor'sName: LIc.No: APPLICATION /PERMIT 6 1
Architect/Engineer. Lic No. BUfLDINGELECTRICALFLUMBING-MWHAMCAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE. - BUILDING PERMIT INFO
Address: PERMITISSUANCE O ❑ 1:1 -
LICENSEDCONTRACTOR'SunderDECLARATION
withSy on7Othatlamlk 3.fth. ur ..idPa fehapler9(commenc APPLIANCESAESTDE L JOB DFSCRB'IION
ingwBh Sectlon force of Divfect. ofthe Buslnessand ProlesslonaCode,and my
license 1.in full toren and dlM. P
License Clanir.If
Date CContronte •�R ( , _1s y�q, - ,
actor frTmp, r, \�JIV�JIJ W
ARCH1=5 DECLARATION 201-1000 A.
�OZ ]understand myplansshallbeused aspublicrecords. OVERIODO SQ.FT.FLOOR AREA S/e.Q.FT.
O
Iry
< Licensed Professional GNS C
<Z
y OWNER-BUILDER DECLARATION CIR T M
p,❑L IhembyafOrenthetlamexempsfromthe Contractor'sLicense Lasbfothe
oO O`r following reason.(Section 70315,Businessand Professions Code:Any cityor POLE
county which requirma permit to construct,alter,Improve,demolbti,orivpair
any hrocture prior to Its Issuance,also requires the a ppliant for such permit to DRVICEq
< file a signed statement that he is licensed pursuant to the provisions of the
a w InContractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SW MM NG IY OL ELEC C
O tion 3 ofthe Business and Professions Code)or that he b exem therefromand VALUATION
5 the Nisi.far the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURFS ��
�QO
applicant fora permit subjects the applicant to a civil penalty virus more than �O.V//�im�y/
Eye hu a dollars(S500).u NEW RESIDENHAL ELECTRSQ}T. STORIES TYPE CONSTRUCTION
as owner of the property,or my employees with wages as thele sok
�7Q sampensatton,wBIdolhe...d Prandthestructure Is Code:The ot intendedContractor or icerse dfor
Law -
$�O sale(Sec.7014,Business and Profession Code:The Contractors Llcerse Law
NIS2 does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RIS.UNITS
who does such work himself orthrough his own employees,provided that such
improvements are not intended oroffered forsale.If however thebullding or TOTAL:
Improvement u sold within one year ofcompletion,the owner-builderwill have
threlenof proving that hedid notbuild orimprove for purpose of sak.). QTY. PLUMBING PERMIT FEE
uUI,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCE
contractors to construct the Project(Sec.7034,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such p3ojects with a A FEE SUMMARY
c,,.�t[[actons)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICELJ I am exempt under Sec. B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm that 1 have o certificate of coerces m opytnsure,ora RE Farr N
certificate of Worker CompensaUoninsurance oracertified copy thereof(Sec. GAS F.A.SYSTEM-1 INCA OUTLETS PARR FEE Y_ N—
Policy
lab CJ
RECEIPT p
Polity#
CoS EA.SYShT1-OVER 4(FA) BUILDING DI VI510N fiif.5
r1om any
Cenified copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
❑Certified copy is filed with the city inspection division.
CERTIFICATE OF E)(EM PFION FROM WOR KERS' GREASE TRA' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."17. Date RCCCI f#
(ThNsection need not be completed if the permit Is for one hundred dollars
($100)or less.) WATER HEATER W/VENT/ELECIR ENERGYFEE Y_ N_
I certify that In the performance ofthe work forwhich this pemnit is issued,
I shall not employ any person in any manner so n to become subject to the WATERSYSTEM/TREATIN'G
Workers'Compensatlon laws of California.Date PAID
O Z Applicant - NEWRESIDENTIALPLMB. SQ.FT. Date Recei t#
Z O NOTICETO APPLICANT:H,after making this Certlficateof Exemption,you
should become subject to the Workees''Comperoation petwWons ofthe Labor r TOTAL: _
CCN Code,you most forthwith comply with such provbions or this permit shall be BUILDING FEE 10-0
W j deemed revoked.
cONSTRUCFION LENDING AGENCY SEISMIC FEE
1 O Ihercbya(firm that there b a construction lending agency for the performry TOTAL: ELECTRIC FEE
Z kforwhich this permit is beaed3097
(Sec. ,CIv.CJ
(� O anmof Ne wor
Lender's Na PLUMBING FEE _
LL t— Lender'.Addres.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEL
OW I nertifythat l have read lhbappilatmnand statethatthe above information
1 rormct.lagme tocomply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
elating to building construction,and hereby awhorfm representatives of this
N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree save,indemnity an d keep harmless the City of Cupertino - Date Receipt#
V agaimt Rabes;pd n dexpen.es whi yinany ayaccrue AIR HANDLING UNIT(TO 10,000CF11) SUBTOTAL:
City en o gr' AIRHANDLINGUM'f(OVER10,000CFM) CONSTRUCTION TAX
SORSIrenApplicant/Contractor to EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicantor futum Wildingoavpara mreor handle haeardous HEATING UNIT CEO I0,030 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? - HEATING UNIT(OVER 100,000 BTU)' TOTAL:
❑ Yes M No
Will the applicant orfutue building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS1LNCFg,DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP CHP OR 100,000 BTU)
4Yes ❑No
have"adthehavardousmaterialsrequirementsunderChapter6.95of BORER-COMP(OVER 100,9W BTU) �U 'i.� IJ�I
the California Health&Safety Code,Sections 25505.25533 and 25534.I
underhand that if the building does not currently have a tenant,that it is my NEW RFSTDENT(AL MECH. - SQ.FT. #.,' ,,.4,
responsibility to notify the occupant of the requirements which must be met . Clt'j -9 01pe,"BO
prior to issuance of a Certlticatc of Occupancy.
Owner or authorized agent Date ISSUED BY:_
TOTAL:
OFFICE COPY