22395APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification
Building Address: ..
PERMIT NO.
22395,
neons one:
Pei-, VL e+-skc 015)3- -gO5�1
CITY OF CUPERTINO-6UILDINGDIVISION
APPLICATION I PERMIT
BUILDING-ELECTMCALPLUMBINGMECHANICAL
�' 7
C tractor'. Nome• No:
r W Scr' �J 1015
CATEGORY CONTROL N
"b' BUILDING PERMIT INFO
Architect/Engineer. Lk. Na
ELECTRIC PERMIT I {'
Address:
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I berebyaffirm that l am Licensed under provisions of Chapter 9(commenc.
Ingwlth Seal..7000).(Division3 ofthe Buelnemand rrofesslonsCode,and my
Ifcense is in (u o���ggq�nd dfect. ij A_�^l
Liwnse
Date Contractor
ARCHITECTS DECLARA710N •`1j
(understand my pions shag be used aspublic recoNa
Licensed Professional
OWNER -BUILDER DECLARATION
lwing affirm
nethatlamexempt(romtheContractor'sLicenselawforthe
(ollowinreason.(Sealon7031.5, Budssand Prons fessioCode: Any city or
c.untywhich requires a permit w mnstrua, site, Improve, dennlish, of repair
anystmumpdorwitsbmame,aLwrequimatheappllcentforsuchpermitto
file a signed statement that he is Lirensed pursuant to the provisions of the
Contraaoes License Law (Chapter 9(mmmenclng with Section 700D) of Dial-.
alon3 of the Business and Profealons Code).rtha he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by anyx--1J
Applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars ($500).
❑ 1, as owner of the property, or my employees with wages as their sale
mmpereation,"I do the work and thestmaure I. not Intended or offered for
sale (Sec 7040 Bushes and Professions Code: The Contractor's License Law
does not apply to an owner a property, who Wihfs or Improves thereon,and
whodoessuchworkhimseif orthrough hisown employees, providedthatsuch
Improvements are not intended oroffered forests. If, however, thebullding or
Improvement iseold within one yearofcompletloo, the owner-bu8derwill have
OUrkllyden of proving that he did not build or improve for purpose.( sats.).
LJ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7070, Bushes and Professions Code:
The Contractor's Licence Law does not apply to an owner of property who
WPM. or Improves thereon, and who contracts fou such pm (ojewith a ywactor(s) licensed pursuant to the Contractors Llcenx Law.
cr_
LII am exempt under Sar. B k P C for this reason
APPLIANCES -RESIDENTIAL
JOB DPSCRR'fION
/a L 1 `, ,
PANELS
Up TO 200 AMPS1
OVEK00AMPS
OVFR iWOAMPS/
ET.
G V B ;� U. T E R.
S/SQ, FT.
SICNSELECTRICAL '
SPECIAL CIIRCUIT/MIST
TEMP. METER OR POLE INS(.
POWER DEVICES
SWIMMING POOL ELECTRIC
OVCLE.ISSW[,fCFiESH%MtES
VALUATION
(/DqO�
Q '
NEW RESIDENTIAL ELECTR SQFr.
STORIES
TYPE CONSTRUCTION
-
TOTAL:
QTY;. PLUMBINCPERMIT FEE!.,FLOOD7ANE•
PERMIT ISSUANCE
ALTER -DRAIN k VENT - WATER (EA)
OCC.GROUP
RES. UNIT;
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
OUTSIDEFEES
DRAINS. FLOOR ROOF, AREA, COND.
FD('NRFS. PER TRAP
SANITARY Y N_
RECEIPT N
Owner - Date
WORK MAN COMPENBATION DECLARATION
QI hereby affirm that I have -a Indo ate of consent to f theme, of a
3800,certif teo(Workere C.mpensatlonlnsurance oracertified copythereo((Sc.
Poll Gb CJ
I'oliry N
SCHOOL TAX Y N -
RECELL7 M
GAS EA SYSTEb1I INCA OUTLETS
PARK FEE Y N_ -
REC®T M
Com
,�yny
- GAS A) EA. SYSTEM -OVER
BUILDING DIVISION FEES
_
LJ Certified copy is heed with the
Certified ropy V (Bed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
• COMPENSATION INSURANCE,
(Thlsseaor Wl.n need ncomplied 1(t W permit hirn one hdre
und dollars
(5100)orfeas)
the perfornunm o(thewwk forwM tM rmlt is issued,
1 shall note y any perw in any manner so jea to the
F..'
Wor 1a?'t o sac nG o Ilfomla. Dat
AnallNOTT an
CREASE/WDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Remi t#
GREASE TRAP
SEWER -SA STORM EA,200FT
WATER HEATER W/VENT/FI-ecTR
ENERGY FEE Y N—
—
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFf.
NOTTCET LICA ;R,a a mak ng Certificate of Exemption, you
should bemmea jM to eW m'Compeivationprovlslonsoflhe Labor
Code, you must forthwith romp th such provislom or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there As a construction lending agency for the perform
arm of the work for which this permit is Issued (Sec. 3097, Civ. C.)
Iender'Name
Leadcr.Addreas
I certlfythat I have read thl,appBatlonand statethatthe abovn information
ts cormct. I agree to comply with all city and county ordinances and elate laws
PAID -relating to building construction, and hereby authorl,m representatives of this
citytoenterupontheabove-mentioned property for inspection purposes.
(We) agree to save, indemnify an d keep harmieas the City of Cupertino
againstliabilities, judgasents, costs and expenses which may In any way items
against said City In consequence equnce of the gra ruing.f this pemNt.
'TOTAL:
WILDING
FEE
SEISMIC FEE ?q•
- TOTAL:
ELECTRIC FEE
PERMIT FEE..
PLUMBINGFEE -'
.'MECHANICAL �
PERMTTLSSUANCE
-
ALTERORADDTOMECH.
AIR HANDUNG UNIT (TO 10,000 CFM)
MECHANICALTLE '
FEE —
-
t# 'Date Recei
P
SUBTOTAL'
AIR HANDLING UNIT (OVER IQ= CFM)
CONSTRUCTION TAX
'
Signature of Applicant/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or hand lc harrdous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Ilealth and Safety Code Section 25532(a)7
I-1 Yes - �] No
C 111theappllantor umrebuildiagoccupant mecqulpment ordevicns
which ens t hacardous air c.maminants ea defined by the Bay Arca Ah
Quallty Management DkMa7
4 Yea Fl No
s ereadlhehaza ousmaterfalsmqulmmnhunderChapterR95of
the 11 mla lfealth A Safety Code, Sections 25505, 25533 and 25534.1
.0 enla dthatifthebulldingdoesnotounentlyhaveatenanithatltVmy
ons' iliT,A notify the occupant of the irements which sat be met
pri IaslydKe ofa Licata of Occup
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
I Date RCCet#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
�•y
I.Jt
.VENTILATION FAN (SINGLE RFSIDI
ISSUANCE DATE
-
! a ] 1®
�I,I
Wed f/ MCN
��
ISSUED BY:
BOILFR-COMPOIDs OR100,000BTU)
BOILER-COMP(OVERi(A,0008TU)
NEWRESIDEN7IALMECFI. �,FT
auth. a At ate
TOTAL:
OFFICE COPY ' /\