22668 I
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
22668
1268
one:
O CITY OF CUPERTINO-BUILDING DIVISION
cmbattnr. ams: LIc.No: APPLICATION / PERMIT
Arthltect/Engineer. Lk.No; BUfLDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL It
i
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add r
Iheby a SEDCONTR DECLARATION PERMTISSUANCE -
V
thrum th
umthat an,licensed
under provisions 9(mnc AIILIANCSRESIDENTIAL �❑'V`�L�la�`V-HON
mgwithSection
nDivem3oftheBuMmandPmfmiansCoeand108 DESCKI
license I.I.full fmce and did. PANf75
LicenseChum
�
❑
Lk.p
Date Contmttor
— UP TO 2DOAHM IMP—
ARCHITECTS DECLARATION 201-1000 AMPS
pp uMtY 2 I understand my pbn.bal be used as public records. OVER 1000 AMPS �^SQ.FT.FLOOR AREA $/SQ.FT.
00
Z' Llmnsed ProfmW OWNER-BUILDER DECLARATION SIGN$ELECTRICAL N
L.f y 1hembyafOrm that lam exempt from the Contractor's License Law for the SPECIALCIRCUIT/MISC i ' "
2.o 'u folowin reason.(Soctloe 7m]S,Buafnm and Pmfmlens Code:An city or I v.✓ l
F,zQ cmntywhkhmquimsapermittocomtmMalter,impmve,demolish,ormpalr TEMP.MUTES OR POLE INST. �/
.6s a eystmctureprlortoibtwaance,a laorequirntheapplicantforsuchperMtto
ryL U file a signed statement that he le,licensed pursuant to the provisions of the - -R DEVICES _ _
30G Contractors License Law(Chapter 9(mmrrcnctng with Section 7000)of Divi- SWAIMINGPOOL ELECTRIC
elan 3 ofthe Business and Prefmlom Code or that he bexempt theref meed VALUATION
�n the basis for the alleged exemption. Any violation of Section 703L5 by any
applicant fare permit subje*u the applicant to a civil penalty of not nnre than OUTLETSSWITCHESFD(TURES
flKLIllialdred dollars($50e. NEW RESIDENTIAL ELECTRSQ,FT. STORIES TYPE CONSTRUCTION
❑❑ �n a owner o(the property,or my employees with wages as theh role
ce .pensation,wllldo the work anotneatmRurc tsl101lntended or offered for
O as &.7054,Bu.lneu and Profenlon Code:The Contractors Llnne law
S$ d not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
whodaes such work himself or through his own employees,provided that such
Improvements are not Intended oroffemd for sale.If,however,thebulldingor TOTAL:
Improvement V sold within eneycarolmmpltt Wes,the owner-bu0derwW have
thiLbiLdenof provingthat he did notbulld or improve forpurposcofule3. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed pFRMITISSUANCE
ttorstoc tmdthepmject(Bee.70f4,Bu.Wmand ProfmWn Code: eft
e Contnctor'e License law don na apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves therms,and who mntram for such p(ojecta with a FEE SUMMARY
ctor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B &P C for this reams
Owner Date DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N
WORK MAN COMPENSATION DECLARATION RECEIPT N
FIXTURES PER TRAP SCHOOL TAX Y_ N_
Of hereby affirm that I have a cenl0cate of consent to opytheure,ora RECEIPT X
relicy#eofWorkeri Campenatlanlnurannorarertlled mpythereof(&c. GAS E.A. YSrEM1 WG4 OUTLET /Mti PARK FEE Y N
RECE3800,lab C.)
Cffom a GAS P.A.SYSTEM-OVER DING DIVISION FEES
Certified copyb hereby te
Certified copy b(fled withh the city
Inpettion divisors. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
ity
CERTIFICATE OF EXEM FT ION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER- STORM EA mm;1. Date Recci tM
(Thisco
his section need t he completed If the permit b Were hundred dollar
($100)mlm.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I nnmempothe performancesfth nnerwmtobthispermitlahailed,
I shall not employ any person In any manner at n to become subject to the WATER SYSTIM/TREATING PAID
Workers'Compenutlon Lawa o(Glifomla.Date
Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recel NI
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Hshould became subject to the Workers'Comperwtion provision of the Labor TOTAL:
cc N Code,you rnuatfonhwith comply with such provisions or this permit shall be IBUILDING
deemed Invoked,LU
C ee . CONSTRUCTION LENDINGAGENCY SEISMIC FEE
1 hereby affirrethat there b a mratmction lending agency for the perform ELECTRIC FEE
Z ance of work for which this permit b Issued(Sn.3097,Civ.C.) TOTAL: 4� X
U O Lender.Nan: PLUMBING FEE
LL F Lendcr'a Addrea. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrti(ytbatlbave read thbapplcatlanand state that theabove Information
binned.Iugreetocomplywlthaltttyand muntyordWanmandrtatelaws PERMTTISSUANCE FEES PAID:
1 relating to building mntmction,and hereby authorlu representatives of this
H Z city to enter upon the above-mentioned property for Inspection purposes. ALIIIIORADDTOMECH. Date Reeei ttt
_ (Wel agree qquv$a Indemnity an d keep h rmim the City of C pc loo
agalntllabll eyNgfrmnb, mend expel kh may in any aye a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agi old Itt'�i onu4.' reofth l I Tibio pertnit.
aRHANDLING UNIT(OVER 10,B00Clml) CONSTRUCTION TAX
si a of Applicant/Contra a EXHAUSrHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hsvrdous HEATING UNIT(TO 100,000 BTIJ) Date Redel til
material as defined by the Cupertino Municipal Code,Chapter 9,12,and the
Ilealth and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTUs TOTAL: ♦ //\
1:W1
Yea No
Will the
applicant
or tore in Ilding occupantusc equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit harardou.air mntamiunb as defined by the Bay Arca Alr
allty Management District? BOILER-COMP QH POR 100,000 BTU)
Yes ❑No
havereadthehaudouamateriabrequimr nbunder Chapler6.95of BOILER-COMP(OVER 100,000 BTU) 4—•G4t��
the Gli(omh Health&Safety Code,Sections 25505,25533 and 75534.I / Xkpk
understand that if the building don not currently have a tenant,that it 6m NEW RESIDENTIAL MECH. SQX-T Nr —R•
responsibility to notify the occupant of the requirements which most be met P 11!r 1
prior to ksuance of a Grtlfkate of Ocmpanry.
Owner ar aulhMud agent Date TOTAL: ISSUEDBY:
OFFICE COPY