22865APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
BaldingAddrem: � �S16W '17411e.
PERMITNO. `
.. - 22865
one.
A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING-ELECTRICAI-PLUMBINGMECHANICAL
�`� If
Cc 4,s Ohi N'
*hItan
CATEGORY'
CONTROL It
� . Lk. No-.
Q'i'r'. , ELECTRIC PERMIT+ ".t FEE,.'
'' (BUILDINGPERMITINFO
Address:
.PERMIT ISSUANCE
191 71 L1 ElL
IC NS C
CONTRACTOR' DELARATION
Ihereby
ion7OOO'hat lamlcen3.ftheunder provisl d ofChapter9(commen
IngwlthSection7000)ofDlvfect. o(theBushes a dPro(esslonsCode,and my
Ilcenmiein fu orc�,apd effect. �j.l %(p�JSJ/%J/
License CWee/ — 1Rk.p�
�p�%Contoator
Datet
AIPIPLIANCFSRESIDENTIAL -
-
PANELS
JOB DESCRIPTION
9 .
/
($( �/ (�CHITECFS DECLARATION
IuMeratandmyp6rashallbeusedmpubkcremrde
-
]Ol-1(100 AMPS
OVERIMOAMPSII
1V'
rh"TRr
S/SQ, FF.
Licensed Profeesional
SIGNS ELECTRICAL
IAS.
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's Llmnse Law for the
following reason. (Section 7MLS, Business and Professions Code; Any city or
countywhichrequlruresaper ttowmtmd,alMglmpmve,demolish,orrepair
anystcture priorto its biriance,aisnrequiresthe applirantfor such permitto
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License law (Chapter 9(mrrmcncing with Section 7000) of Divi-
knoll of the Business and Profemiora Cade) orthat he is exempt therefrom and
by any
the basis for the alleged exemption. Any violation o(nalty nor room
applicant fora permit subjects the applicant to a civil penalty o(nct more than
flue I, as o nerdolof he pr).
c ❑I, as owner a( the property, or my employees with wages r their dole
compensation, the the e nded d for
UT
/f
/ v IJ
Gr .
J
1'
SPECIAL CIRCUIT/MIST
TEMP. METER OR POLE INST.
WE POWER DEVICES
SWIMMING POOL ELECTRIC
VAL[7��/ SON
T / ✓ 4
1
OUTLETSSWITCHESEXTURES
NEW RESIDENTIAL ELECTR SQ.FL
SIORIFS
TYPE CONSTRUCTION
n.Cde:Ture
Businessand rola Contraot
cola (Sec.7/44, Bueinem and Profemiom Code: The Contractota License law
License Law
does not apply to an owner of property, who builds or improves thereon, and
who does suchwork himself orthrough his own employees, provided that such
OCC, CROUPRES.
UNITS
improvements are not hrended proffered for sale. IL however, thebullding or
Improvement issold within oneyearofcomplekon,theowner-builderwlll have
tp rden of proving that he did not build or improve for purpose of sale.).
1, as owner of the property, am exclusively ntracting with nse
LJ coliced
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
or improves thereon, and who contracts for such pRokdd with e
cq➢.t{aa (s)limnwdp muanttothe Contmdo sLimnm Law.
LH I am exempt under See. B & P C for this reason
TOTAL;
QT Yr'. t.'''.FLUMBING PERMIT `�{FEEi''
PERMIT ISSUANCE
ALTER -DRAIN &VENT- WATER (EM
bTAOD ZDNE
APN
BACK FLOW PROTECT. DEVICE
'. •rfiQE�SUMMARY'y.
Owner Dare
DRAINS -FLOG ROOF,
A AREA, COND.
FIXTURES- PER TRAP
SANITARY Y N�
RECEIPT p
WORKMAN COMPENSATION DECLARATION
❑I hereby affirmcertificate that 1 have a certificate
te of consent to self -insure, ora
certiflrorkers'Compeneatlon Wuranceoracertl(led ropythercof(Sec.
Poli laAb bCj CO
Paltry It
SCHOOL TAX Y_ N_
RECExT p
GAS EA SYSTEM -1 INCAOUTLETS
PARK FEE - Y N
RECEIPT p
Cam any
Certified copy is filedherew th the cityed.
�Certifled copy is filed with the sty Inspection division.
GAS EA. SYSTEM -OVER 4(EA)
GREASEANDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thlasedion nee becompleud ifthepermat isforonehundred dollars
orlem.> 1
Iccd,ylM1at the pedormanceo hewarkforwhichthle permiH issued,
I shall note y person In y manner m m t c b jhe
s
Workers' o n ws ornla, Date /
Appll of
PAID
Date Recei t#
SEWER -SANITARY -STORM EA 2DOFF
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N —
PAID
Date Recei t#
WATER SYSTEM/TREATING
NO O ICA : a erma ongtm rate oprovisions
should become subject the Worken'Compe on provlsloca of the Labor
Code,yuumustforth thcomplywithsuch lora orthis permit shall be
deemed revoked.
NEW RESIDENTIAL PLMIL —_SQ.FL
' TOTAL:
BUILDING
TOTAL:
C STRUCTION LENDING AGENCY
I hereby affirm that there isa construction lendingagenry, forthe perform
anu°fthew°rkfor whlchthis per isissued (Sec. 3097, C1v. C.)
Lenders Name
Lender'sAddmm
I moutythatl have read thisapplicati°nand state a do
uc°rrectl et° comply with andtyabyauthyordinanms and state s
relatingt all Ing construction, and hereby authorize representatives
city to eru on the above-r®ntomed property for inspection purposes.
(W a to. save, indemnify an d keep harmless the City of Cupertino
.gat t.11 Bitks, adg , mets and expenses which may In anywayacerue
Id City in cc ence of the granting of this permit.
SEISMIC FEE
ELECTRIC FEE
.�
QTY.' .C'MECHANIGAL'PE@INIT?"•FE&::
PERMTTISSUANCE
ALTER OR ADD TO MUCH.
AIRHANDLINGUNT(TO10,000CFM)
PLUMBING FEE
MECHANICAL FEE
FEE 1L-�3�2
O
D to Reeel t#
SUBTOTAL:
AIR HANDLING UNIT (OVER IQOOOCFM)
CONSTRUCTION TAX
to
EXHAUSTHDoD(W/DUC71
CONSTRUCTION TAX PAID:
Signatursa or
HAZAADOUSM U ALS DISCLOSURE`
Wlllthe pplican�rfulurPbull ng pant store or handle i rdens
material efinedb the Cu d M ic1pal Code,Cha er9.1 andthe
Healthan SafetyCode Ss a)7
❑ Yes o
3a
HEATING UNIT (TO 100,000 BTU)
Date Recei [#
HEATING UNIT (OVER 100,000 BTU)
. -
TOTAL:
VENTILATION PAN(SINGLE RESID)
ISSUANCE DATE
P�'RRp�
®
Will the applicant orfuNre building occupant use equipmentor devices
which emit havrdous air coma nis as defined by the Bay Area Air
Quality Management Distk
BOILER -COMP OHP OR 100,DW BTU)
Yes o
4have
BOILER -COMP (OVER 100,000BTU)
mail the haxar pus materials requlretrentsunder Chapter 6.95of
the California Health &Safety Code, Sect Ions 25505,25533 and 25534. I'
understand that if the building does not currently have a tenant, that It is my
responsibility to notify the occupant of the requirements which ..at be met
prior to issuanceof a Cedifeste of Occvpanry.
_ fF x-�✓
- p Cuss
p1l(� aa.{.
[aa„ Q4,
e
ISSUED
NEW RESIDENTIAL MECH. 5Q.FT.
Owner or authorized agent Date
TOTAL:
OFFICE COPY