23855 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification I PERMITNO.
Building AdIress:`_wy`f'`Trr_wJ �. e 23855
nen � one: A
CITY OF CUPERTIN66UILDING DIVISION
Co
me: Lie.N. APPLICATION / PERMIT
. p BUILDING-ELECTRICAL.PLUMBING-MFGHAMCAL CATEGORY CONTRQMII
ArehlD�er: Lie.Na. {�
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Address: EN PERMIT ISSUANCE I� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby on7OOhatlamlcrosed heunder BusiprovislossofChapterg sCode,mmenc APPWANCESRESDENTGL JOB DESCRIs770N
Ingwlt ISI NEE
Dlvblan3o(the Business rad Pro(eselonsCede,and my
(cense lsintuBf and d(M. .2^/R,/ PANELS S OI1� 1 . fA_L�
License Chss Lie# �l�l 10 IQ�V Vrt ��I�l
Data Contractor 2011000AMPS
IS
RCXITECTS EC RATION
rc0 O I vndenta rad my plan shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA f/SQ.FT.
Licensed Professional SIGNSELECTRICAL. / ki A LET) I N
N
<6 OWNER-BUILDER DECLARATION
py SPECIAL CIRCT/MLSC 1,�(•
p„ Z owing raffirm son. SutL7031exempt from s a Contractor's License LawAny cit or �p � C�
7p µ�^j he
following reason.(Section 78715,Business and Pro(embne Code:Any city or (`�J b.
O�ZTEMP.METER OR POLE(NSI.
� countywhich requ4esapermltromruvuct,alter,improve,demolish,arrepalr
a anystructun prlortolta Wuamc alsoreqube;theappUmntforsuch perndtto POWER DEVICES
E 5 0b a signed statement that he b licensed pursuant to the provisions of the
f6ilOµ Contractor'sLice.Taw(Chapter9(mmmendng with Section 700()of Divi- Sypt{hgNG Root ELECTRIC
(.3D atom 3ofthe Buslnnsand Pmtesslons Code)orthat hebesempttured. and VALUATION
O the baste(or Me alleged exemption. Any vlolado i a(Section 7m15 by any OUTLETSSWITCHESHXTURES /1 A
fivehuntred spermit$50(B. theappllcanttoa dull pansltydmat more than G.�
liE]1,as
of hepr. NEW RESIDENTIAL ELECTR SQ.Fr. SIDWES TYPE CONSTRUCTION
7 6 ❑I,a.owner of the property,or my employees In with wages n their sole
cele 9Z Ron,w0ldothe work eedtheetrude: le not Intended or offered for
O rale(Sec.704d,Bu.bicae and Professions;Code:The Contractors License Law
1!j$$ dors not apply to an owner of property who Wilds or lmpxvn thereon,and t OCC.GROUP RFS.UNITS
EL: who doeasuchwork himtelforthrwgh hisownemplayees,provided that such
Improvements are not intended oroffered forsale.If,howe regthebullding or TOTAL:
Improvement is sold within one yearof completcM the owner-bullderwill have
thRb,rden of proving that he did not build or improve for purpoxolmle.). QTY. PLUMBING PERMIT FEE HCODZONE APN
LJ 4 as owner of the property,am exclusively contracting with housed PERMIT ISSUANCE
mntnctan to construct the project(Sec.70K Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER[[A)
Wilds or Improves thereon, and who contracts for such ptnjecs with a FEE SUMMARY
gB�Tactor(e)Bcenmd pursuant to Me Contractos'e Lkense Law. BACK FLAW PROTECT.DEVICE
c E31 am exempt under Sac. B k P C for this masonOUTsi LIP.FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
• Owner - Date RECEIIT#
WORKMAN COMPENSATION DECLARATION �T.U�S PER TRAP SCHOOL TAX V N
❑I hereby affirm that I have o imumne of aoftif to self-Insure,ora RECEIPT#
certillote olWorken'Compenutrlo�nlnsunnm ora certifkd ropythemof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARKFFR Y_ N_
:c'Y b_�ty���
RECEIPT#
Pott # CAS PA.SYSTQ.fAVERd(EA)
Co��mPPany BUILIIING Di VISION FEES
ertlRed copy's led w tum a ed.city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE /
Certified copy b Tibet with the city Wpectbn division. ` CC,J.,(/Jl s
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID-
COMPENSATION
COMPENSATION INSURANCE SEWER-SANITARY-STORM E.A.200FT: Date Rewi tk
(Thlssection need not be completed If the permit Is forone hundred dollars
a100)nr lese0WATER HEATER W/VENT/ELECT-R ENERGY FEE Y_ N_
I certlfylhat N the pedormanceof the work forwWch this permit b bored,
I.hall not employ any person In any manner so n to become mbjed to the WATER SYSTEM/TREATING
Workers'Compensatlon law.of California. Date PAID.
O Z Applicant NEW RESIDENTIAL ELMS. SQ.Fr. t ted
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor T
jj
W Code,you=at forthwith comply with such provisions cribs;Nrrnit shall be BUILDING FEE
W j deemed revoked.
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby aork for w there bammtructlon lending agency CIV. .) perform TOTAL: ELEL ERIC FEE
0 ZO anceer's Name WING
which this permit bbmed(Sec.3097,CIv.CJ
Tonder'.Name PLUM6ING FEE
LL F land.e.Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
lcedif1 tbapplltnthabo �fotim
OWbrourred. agmtocomplywdtyand=nyordnannsandM.t,l.ws
PERMIT ISSUANCE PEES PAID:
>_ relatingtobulldng constuctim,,.nd herebyauthmiza rrepreeentativnof
this
I.— y city to enisrupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V agalnstlb Titles,tAdgmento,r sandexpenseswhhh maymanywayacrnse AIRHANDLING UNrr(TOIO,"CFM) SUBTOTAL:
against d styU segon of the granting of this perml.
AIR ITANDUNG UNTE(OVER 10,000CFM) CONSTRUCTION TAX
Signature.(Applicant/Contr mr Usib EXHAUST HOOD(W/DucT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappllcant or frturebullding occupant sloreor handle hazardous HEATING UNIT(TO 100,000 BTI]) Date Recei Up
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - V�
ITnith and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TO L. `Q
Yes No
Wlllthezpplimrat Rion,building occupant use equipment ordevico. VFNOLATIONFAN(SINGLERESID) ISSVhCV 10TE
which emit haardous air contaminants as defined by the Bay Area Air 11� 1`a N
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
yrs
No JUL 14 i9
4haveread the
ealth&afesCode,brcam255n(aunder nd255Chapter 6.95of BO LER-COMP(OV02100,000BTU)
thaCa erstlod laat if the
building
Code, of Tomedyh have
33 atandt,that 1
understand that lithe Wilding don not comedy havcatenanl,that ilbmy NEIN RESIDP.MIAL METH. SQFI /�
rexponaiblllly to not lfy the occupant of the requirements which must be mot CITY ut t,Uerm
prior to issuance of a Certificate of Ompancy. ,/�
Ownerorauthmired agent Date - TOTAL: ISSUED BY: VsA_/rf.r
OFFICE COPY