19807 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Pro'ect Identification PFRMITNO.
f.Ilding Add res,: 19807(�0�J
RS 1�ac l9 TU{ I
'Cs ams: Phone: A A A
UI'sIA CITY OF CUPERTINO-BUILDING DIVISION Oy D
c.no-actor'a Narre: Lm.N.: APPLICATION I PERMIT
BLnDINGELECTRICALPLUMBING-MFGHAMCAL CATEGORY CONTROL a
Architect/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMIT ISSUANCE
oLI 'NS a CONTRACTOR'S oDECLARATION
❑ ❑
I herebyaffirm I licensed rvlaomo(C9(mmAPPLIANCES-RESIDENTIAL SCRB'fION
InthSonfa00()ofDivifofthe Buslncnand Pro(essionsCode,and my JOB DF
liceersoi.in fail for¢and effect.
❑
PANES
License Clan Lica V�ST�
Date Contactor UP TO 2D0AIY[PS
ARCHITECTS DECLARATION 201-1000A.MI'S
rem Z I understand my plans shall be used as public records OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
OSIGNS ELECTRICAL
z Licensed Professional
G y OWNER-HOLDER DECLARATION SPECIALCIR T/MLSC
p., L affirm I hereby arm that am exempt from the Contractors License Law for the AWf
ZO '- following reason. 70115,Business and Professions Code:Any city or
O Z t- TEMP.METER LE N
pp rountywhich rcmi
qulmapert tocontrud,alteq Improvern
,del(ah,orrepalr
^ Q anystm=mpdorto BsL ancgaL requimtheappBcantforauchper tto IVERD
Eli,a signed statement that he u hema d pursuant to the pmWion of the
a w G Contractors License Law(Chapter 9(commencing with S cti. 7000)o(DIW- 5 M N L E
ehm3.fthc Business and Profession Code).rthat he is VALUATION
exempttherefromand ON
6 5 the basis for the alleged exemption. Any violation of Section 70315 by any O E W( XTOR �/) Irl
ml -
00
appllcantforapertsubjectsthe applicant to a civil penalty more than V ll
five hund�dollars(5500).
�L j-),ams owner of the property,or my employee with wage a,their sole E'`I L E SQ'FT' STORIES TYPECONSTRUCTION
k�a rompensadon,will dothe work,and the structure is not Intended or offered for
❑ sale(Sec.7014,Business and Profesion Code:The Contractor's License Law
q�$ does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RFS.UNITS
who does such work himself orthrough hisown employees,provided that such
improvements are not Intended oroffered for sale.If howevegthebuildingor TOTAL:
improvement bsold withinoneyearofcompldion,theowner-buiMerwlll have .,r-� `
th�e,¢+rden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING3aERMF' '" 'E FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed p Iq'ISSUANCE '
rontractorstoc.nlructthe project(See 7044,Business and Profession Code: - t
The Contactors License law does not apply to an owner of property who
Wilds or Improve thereon, and who contracts for such piajeev wfth a -DRAIN&VENT-WA (RA)
cgiytpnor(s)licenxdp rut to the Contr Wars &sense Law. - I FEE SUMMARY
lJ am uempt eco e&P C (or fhb mason gA W PR�OCT,ECT. OUTSIDEFEES
ti RAINSI K 'SANITARY Y N
Owns Date - RECEIVE p
WORKMAN COMPENSATION DECLARATION TllRES I'ER TRM SCHOOL TAX Y_ N_
I by affirm that I have a eertificate of consent to selEbuure,or a
cem to of Workers Compenadoninsurance ora certified copythereof(Sec.
RECEIPT
ISM,Lab C.) GAS EA.SYSTEM-1 INC.40UTLEIS PARK FEE Y_ N_
- RECEIPT a
Pdiry p GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING FEC DI VISION FEES
Certified copy b M1erebyth the city CREASE/INDUSIRL WASTE INTERCEPTOR - PLANCHECK FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRF-ASE'IRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.MFT. Date RCtt'I I#
(This section need not W completed If the permit b Errors hundred dollars
($3 W)orBlyth WATER HEATERW/VENT/ELECTR ENERGY FEE Y' N_
Icertloss.) tithe e
prformanceofthe work forwNch this permitbbsued,
I shall not employ any Person In any manner so as to become subject to the WATER SYSTEM/TREATING Workers Compensation Laws of Califomla.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Dale Recef t#
Z O NOTICE TO APPLICANT If,after making this Certificate of Exemption,you
-F should became subject to the Workers'Compenatlon provisions of the Labor TOTAL:
W Code,you must forthwith comply with such bion or this permit shall
LU j dee
Code,
Py Prov BUILDING FEE r.oU
W —' CONSTRUCTION LENDING AGENCY - SEISMIC FEE
d O Ihereby affirmthat mere Is a construction lending agency for the perform- ELECTRIC FEE
OZ ance of the work for which this permit b Issued(Sec.3097,Cu.C.) TOTAL:
Lender's Name PLUMBING FEE
LL LL 1<ndersnddreas QTY. MECHANICAL PERMIT- FEE
Ow Imrtilythailhave mad thuappliend....dx1atethattheaWwc5tfomatlw MECHANICAL FEE
a rrect.I agree tocompiywith all city and countyordinanceand state laws PERMIT ISSUANCE FEES PAID:
} W mating Wiriu h.gmntructim,and hereby authomce representatives of this
•F city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save, it fy an d keep harmless the City of Cupertino .Date Receipt#
V
against liabilities,lu n ,coat a and expense which yin any way accrue AIR HANDLING UMT(TO 111,000 CEM) SUBTOTAL: I \ -
a aid City In ce of he gra t g of th it.
AIR HANDLING UNIT(OVER 10,00(]C CONSTRUCTION TAX
•
si iof Appliant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Y`
the applicant or future building occupant store or handle haeardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
crialaa deEnd by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Code Section 2S532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: (�
❑ Yea ri No
Willthe applicant or futumbuilding occupant use equipment ordevices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which emit M1agemnt air Distcontaminants as defined by the Bay Area Air PAM,
Quality rout
hamment District? BOILER-COMP PHPDR 1110,000 BTU)
4Yes ❑❑No 1
haveread the bvardousmaterials requirementsunderChapter6.95of BOILER-COMP(OVER]W,"BTU) 1 rV IT J
the Califomb klealm&Safety Code,Section 25505,25533 and 255]4.1 V
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIALMECH. SQ.FT. '
reiponiblllty to notify the occupant of the requirements which must be nM 4.,
prior to issuance of a Certificate of Occupancy. City-of CIInaffino
Owner or authorized agent Date ISSUED BY:� D,/U&L
TOTAL:
OFFICE COPY