23302 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO,
Building Address: 3 3 0 2
i o8 Z l �lEs �� `�� (�1
nenp ame: p C ,A A A A
L�r\tf s'S "L Q96 .c Z CITY OF CUPERTINO-BUILDING DIVISION
Name: 7 �o: APPLICATION / PERMIT
Until J!
• (� BUILDINGII.ECTRICAL-PLUMBINC.MECHAMCAL CATEGORY CONTROL N
.. Architect/Engineer: LIc.No: -
QTY - ELECTRIC PERMIT FEE BUILDING PERMIT.-INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
T hereby affirmthat l am licensed under provisions of Chapter9(rommenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)of DWist..3ofthe Businessand Professions Code,and my r.
license b In to o and effect PANELS
ontrL
Lken RN I& UP TO 200 ANIPS
Date Cactor
ARCHITECT'S ECLARATION OVER
AMPS
Ond 7 I understand my plans shall be used as OVER
public records. . 1000 AMPS SQ.F7.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNSELECTRICAL
Q
following reason. OWNER-BUILDER DECLARATION C C p'
tn` Fn SPECIAL CR2CNT/MLSC
l5e1 V
t.., Ihereby affirm that l am exempt from the Contractor's License Law for the
Z O '� ctlon 7031.5,Business and Professions Code:My city or T E R
0 7 t- TEMP.METER OR POLE INST.
5 county cturc requires permit to msutrouiesetheaprove,demolbh,or repair
. 6 anyatucture prior to lts&aance,also requlrntheappBrantfou such permit to POWER DEVICES
g ilk a signed statement that he b licensed pursuant to the provisions of the 1
a3o,t; Conmetar's Licens,Low(Chapter 9(mmmencing with Section 7000)of Divi. SWEHMING POOL ELECTRIC
C sion3 ofthe Business and PrefessbroCode)orthat he k exem therefromand DA ATION
the basis for the alleged exemptkon. Any violation of Se tion 7031.5 by any OUTLETSSWITCHESFlXfURFS
pp applinntforapermitsubjetstheapplkanttoadvilpemltyofna =mthan
F,R five hundred dollars($500). NEWRESLDENTIALELECIRFC.
7
MI,as owner ofthe property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,willdothe work,and thestrocture le not intended or offered for
.a p
In(Sec.7044,Business and Professiow Code:The Contrato/s License Law _
fyS$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUT' RIS.UNITS
EC who does such work himself orthrough his own employm,provided that such
improvements are not intended oroffered tarsale.If,however,thebuilding or TOTAL:
Improvement issoidwithle oneyearofcompltion,the owner-W Bderwll)have
t eden of proving that he did rand build or improve for purpose ofsakd. QTY. PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively rontrading with Ilmnsed FLOOD ZONE APN
rontndmrs to mrutrut the project(Sec.7014,Business and Prvfesslom Code: PERMIT ISSUANCE
Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VEM-WATER(FA)
Wilds or Improve.thereon,and who contrafor such ppajeeb with a FEE SUMMARY
cgIltTator(s)licensed pursuant to the Corimumes License Law. BACK pIpW PROTECT.DEVICE
L�I am exempt under Sec. B&P C for this mason
OUTSIDE FEES
DRAINS FLOOR,HOOP,AREA,COND. SANITARY Y N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION
�- ❑1 hereby affirm that I have a certificate of consent to self-insure,ora pl%TURES PER TRAP SCI IDOL TAX Y_ NAECFIPT N
cenifioteofWorkers'Competuatlonlmuranreoramrtifiedropythereof(Sec. GAS FA.SYSCt.It IINC.40UTLEfS PARK FEE Y N
3BOO,lab C.) 2� RECEPfN
loliryp VTl GAS FA.SYSTEM-OOVER Com acts �1 �11J BUILDING DI VISION FEES
�Ccrtlfied ropyuherey rmbhed. GRFASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�ertsed ropy u('Jed with the city IrepMion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-SCORN EA.MET. Date Rccci t#
Trhis secttan need not be completed lithe permit k for one hundred dollars
($100)or less) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that in the performance ofthe work forwMeh mit this peris Usved,
I shall not employ any person In any manner so as to becoore subject to the WATQt gYSTFM/TRFA7ING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RFSTDFNDAL PLMB. �.F. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subjM to the Workers Compematlon provisions.(the Labor TOTAL:
N Cade,you must forthwith comply with such provisWm orthbi permit shall be UI DING FEE
W > deemed revoked.CONSTRUCTION is a ON LENDING AGENCY SEISMIC FEE
a U Iherebyarfirnthat there learonwmon kneingagency mrthe petorm ELECTRIC FEE
Z Ince ofthe work torwhich this permit is isued(Sec.3097,Clv.Q TOTAL:
02 Lender'.Name PLUMBING FEE
F- Lender.Address - QTY- MECHANICAL PERMIT FEE
LL U Icertifythat l havereadthetapplicatlonand nate thatthe above information MECHANICAL FEE
O W Ismrme.Iagree to comp)ywith all city and county ordlnanm and mate lawn PERMfTISSIANCE FEES PAID:
>. IL relatingtobullding construction,and herebyauthommeepresentativesofthls
YA city to entero above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. -
? (We)a to sav,indemnify keep harmieas the City of Cupertino Date Receipt#
V agalrut llab Itl a,p gments, e costs n ses which may in anywayaceme AIRHANDLTNGUMT(TO10,000CFM) SUBTOTAL:
agalrut said C' co ence ft canting of this permit.
AIR HANDLING LRU(OVER 10,"CFM) CONSTRUCTION TAX
Sigvurcot pplicant Contras D/ate u EXHAUST HOOD fW/DUC0 CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuure building occupant store or hand le havardous HEATING UNIT(TO 1 OLM BTU) Date Recei
material as defined by the Cupertlno Municipal Code,Chapter 9.1Z and the
I kalth and Safety Code+—Seaton 25532(.)7 HEATING UNIT 100,000 BTU) VIS-11
TOT
❑ Yet . No :
Will the applicant or tuure building occupant use equipment or devices VENTILATION PAN RESID) .ISSUANCE DATE
which emit h wardous air remarries nts as defined by the Bay Arca Air
Qua Ety Management District? BOILER-COMP QHP OR 100,000 BTU)
,] Yes ❑Na
t I have read theta r of matde,Se requ 25505,25533
5 05,255 3 and 255 .I of BOILER-COMP(OVER 100,000 BN) ►g p
i- the California Health&Safety Code,nectiom25lyhave 33and,that
N TYr,
ID
understand that if the the ocupint of to requirmnts tenant that itbmy NEW RESIDENTIAL MECH. SQFT.
responsibility to Issuance I.
of ratifythe
acts requirements which must be rrct CP
prior to Issuance o(a Certificate of Occupancy. C1 Cir '02/y�—"
Owner or authorived agent Date
TOTAL: ISSUEDBY.
OFFICE COPY