22097APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Idemifirelon -
Building Address:
PERMITNO.
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CITY OF CU PERTINO-BUILDING DIVISION
APPLICATION / PERMIT
S BUILDING-ELFCTWCALPLUMBING-MFLHAMCAL
A A
G -72Ar9�.
c°^°raft°r.N,me: Lic.N.:
rchlted Engineer. Lk. No:
CATEGORY CONTROL N.
QTY ;ELECTRICPERMIT ;'114FEE, `'�
'it . 1•. ;BUIL,DING,PERMIT.INFO".
Addimae1 S L"'-6("ORd L"'-d("Ood a
,'
PERh9TISSUANCEF-1
Ll t [ILICF.NS
ED CONTRACTOR'S DECLARATION
]hereby affirm that lam lcmecd under provLslone ofChapter9 (comment-
Ingwith5ection7000)of Dlvialon3ofthe8usinessand ProfesslonsCode, and my
liem. is In full fore and died �1 /,t
C.. LICX %� res 175
AI'I'LIANCESRESIDENTIAL
JOB DESCRIPTION
-
- PANELS
DateClass
Date Contractor r. wrr A.ia.+n Ofgy -112
ARCHITECTS DECLARATION i
I understand my plan, shall be used as public records
IQ 200 AMPSr
�C/
S/SQ. FT.
4 191
201-1000 AMPS
OVER 1000 AMPS
SIGNS ELFGTRICAL
Licensed Proional
Profess
U TER
OWNER -BUILDER DECLARATION
I hereby of Inn that I am exempt from the Contractor's License Law for the
SPECIALCIRCUIT/MLSC
) c R
//��aa�k
TEMP. METER OR POLE INST.RN!�
following reason. Business and Professions Code: Any city or
c°untywhich requires a permit to mwtruct, altep Improve, Eemollah,or repair
/
anystrudure prior to its issuance, also requires the applicant for such permit to
.file a signed statement that he la licensed pursuant to the provbiom of the
Contractor's License Law (Chapter 9(co ensencing with Section 7000) of Divl-
of the Business and Professions Code) or that he la exempt therefromand
the Esau for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjeatsthe applicant to a civil penalty of not room than
five hundred dollars ($5M.
❑ I, as owner of the property, or my employees with wages as t Wr sole
POWER DEVICES
,
SWIMMING POOL ELECTRICdon3
VALUATION
- '
,
OU7LETS5WITCFIESFIKTURES -
NEW RESIDENTIAL ELEC7R FT.
STORIES
TYPE CONSTRICTION
compensation, will do the work and the structure Is not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors License law
does not apply to an owner of property who Wilds or improves thereon, and
who d°easuch work hiendiforthrough his own employees, provided that such
OCC.GROUP
RIS. UNITS
improvements are not intended oroffered foreale. If, hcwcvep the building or
Improvementiss°Id withinoneyearo(compldion,theowner-builderwill have
t49kadeno4proving that he did notbulld or Improve forpurposeofsale.).
Lf I, as owner of the property, am exclusively contracting with licensed
contradore to construct the projed(Sec. 7044, Business and Professbns Code:
- TOTAL:
QIy, 'I",t; t PLUMBINOPERMIT,r"lt '1 ')'FEE 'j
PERMIT ISSUANCE
-
FLOOD ZONE
APN
TTc Contractor's License Law does nor apply to an owner of property who
Wilds or improves thereon, and who contracts for such Inpiects with a
cgy(pactor(s)Rcensed punuant to the Contractors License Lew. -
LJ I am exempt under Sec 8 & P C for this mason
ALTER -DRAIN&VENT - WATER (EA)
.i
,' FEE'SUMMIARY 'J
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR, ROOF, AREA, COND. -
FXTURFS-PER TRAP -
SANITARY Y N_
RECEIPT N
Owner Data
DECLARATION
�( WORKMAN I have
ISI hereby affirm that I have a certiflote of consent to opy lraum or
3800, Lab of Worken'ComperwtlonInsurance ora certified ropy thereofl5ec.
Poli lab C.)
Policy p L✓ G L/7 0c+'LZ-'
SCIi00L TAK Y' N
RECEIIT. M '
GAS EA. SYSTEM -1 INCA OUMETS
PARK FEE Y N
RECEIPT M
Com anY�]wyas a IS
�1 ;�ai
GAS EA. SYSTEM -OVER
tlU1LDINC DI VISION PENS
�Certifled copy V hereby fumlehed.
JSCemfird ropy 6 filed with the city inspection division. .
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCFIECIC FEE
GRFASETRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fhb session need rad be completed R the permit (s (w one hundred dollars
PAID
Date Remi t#
SEWER -SANITARY -STORM EA. 20aFT.t
D1441ar1fWATER
]certify that the performance of the work forwhkhlhle pertNtlabsued,
at m to bemuse subject to the
I shall not employ any person in any California
Workers Compenwtlon Lanae of mla. Date
HEATER W/VENT/ELECTR
ENERGY FEE Y N
PAID '
WATER SYSTEbt/ TRFATING
Applicant
NOTICETO APPLICANT: If, after making thLe Certificate of Exemption, you
should become mbjecttothe Workers' Compensation provisions ofthe Labor
Code, you must forthwith comply with such pro4Lslom'orlhb permit shall be
deemed mocked.
Date Recef t#
NEW RESIDENTIAL PLMB. SQ.FT. .
-
.•
TOTAL:
BUIL INQ ECE
-
SEISMIC FEE
'
CONSTRUCTION LENDING AGENCY
I hereby affirm that there b a construction lending agency forthe perform,
ercv thework for whkhthb hissued (Sec. 3097, Civ.C.)
)
TOTAL:
(70
ELECTRIC FEE
lander'Name
Leader.Address - -
I certifythatl have read thisappllceHonand nate thattheaboveiefornuBon
Iseerrect. I agreeto comply with all city and county ordinances and nate laws
Q4. MECHANICAL'PERMIT - FEET
PLUMBING FEE
I--7—
MECHANICAL FEE
-
PERMTIISSUANCE
FEES PAID:
relating tobuildingmmtrucron, and herebyauthorize representativesofthis
-
citytoenterupontheabove-mentloned property for inspection purposes.
(We) agree to save, indemnify an d keep harmless the City of Cupertino
ALTER OR ADD TO MECH.
Date Receipt#
SUBTOTAL:
against llablltles,)adgments,consand expeneeswhich may in aaywsyaccme
against said City In consequence of the granting of this permit.
AIRHANDLINGUNH(TO10,0D0CFM)
AIRHANDUNGUNH(OVER1O,000cru)
CONSTRUCTION TAX
Signature of Applicant/Contractor Data
EXHAUST HOOD(W/DICT)
CONSTRUCTION TAX PAID:
-
- HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
-
Willtheappllont or future building occupant store or handle hazardous
nuterlala,deflned bythe Cupertino Murddpal Code,Chapter9.12,and the
Healthand Safety Code Ion 25532(x)?
r-11Yes NNo
Date Recei I#
HEATING UNIT (OVER 100,000 BTU)
TOTAL'
^-`
UI'
VENTILATION FAN(SLNGLERESID)
ISSUANCE DATE
fir
Willthe applicant or tuturebuildiagoccupant use equipment or devices
which emil harardous air contaminantsas eleflned by the Bay Area Air
Quality Management Distad?
4Yea 59-N°
hivercadthe harardou• materials requirementsunderChapter6.95of
the California Health &Safety Code, Sections 25505, M33 and 25534. I
8011FR-COMP DHPOR 100,000 BTU)
BOILER -COMP (OVER 100,000 BTU)
NEW RESIDENTIAL MECH. SQ.FT
understand that if the W lld ing does not currently have a tenant, that it is my
responsibility to notify the occupa rat of the mqu lrements which must be met.
p,ry1p_ t°Issuance of Certificate
lav
yo(yOawlpanry.
Z&2,e, %lit. a -/TI KI � 2�
&YHl MM NVR
ISSUED BY:
Owner m.whomeod agent Date
- TOTAL:
OFFICE COPY