22156APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
Building Project Identification
Building Address: l Z` l �""t = _
PERMIT NO.
22156
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUfLDINGELECTRICAI FLUMBING-MECHAMCAL
A
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CATEGORY CONTROL If
BUILDING PERMIT INFO
Arclettect/Engineer. Llc. Na:
QTY ELECTRICPERMIT FEE
Address:
❑ ❑ ❑
PIRhRTISSUANCE
LI NSED CONTRACTOR'S DECLARATION
Ihereby af(1 ihM IMulless!underprovWonsof Chaeter9(coermenc-
IngwlthS u ef00)of Da sion3ofthe Businemand ProfesslonsCode,andmy
Ilcenee ie to (fect.
Dmnl �Lak.p
Dale ntractar
ARCHITECT'S DECLARATION
I understand my plains shall be used as public records.
Licensed Professional -
OWNER -BUILDER DECLARATION
I herebyafflrmthat l amexempt froerthe Contractors License Law for the
following mum. (Section 7ml.S, Business and Professions Code: Any city or
county which requlresa permittoconstruct, alter, improve, deroolkh,orespair
anystructure prior faits issuance, also requtenthe applicantfor such permit to
file a signed statement that he is Bussed pursuant to the provisions of the
Contractors License Law (Chapter 9(mermencing with Section 7000) of Divi-
ivi-
Mon
Mon3 of the Business and Professions Code) or that he 6 exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjeatsthe applicant to a civil penalty of not rrore than
flue hundred1, as of hepro.
compenI, m owner of the property, or he employees with wages r their sole
bnotintendedo iofferedfor
Is (Sm. 7044,flon, Btadotheworrendthes Code:
sale (Sec. apply Business and f property Code: The Contractors License Law
dont notsuch oak owner ofpropertyhis own
nem orterproems ovidedreoRand that such
whodoes ntsaorkhierself dedoroffemdfwne. 11,luonerthebuildingor
Improvereentsarenotintendneyear fcomprmk,the co a builderwili have
improvementlssold withkoneyearofcompletloMthe courser-bullderwlllhave
thC burden of proving that he did not build or Improve for purpose of sale.).
M L, as owner of the property, am exclusively contracting with horesed
contractors to construct the project (Sec. 7064, Business and Professions, Code:
The Contractor's License Taw does nM apply to an owner of property who
builds or Improves therein, and who contracts for such ptojects with a
ce,Iltjjactor(s) licensed pursuant to the Contractor's License Law.
LJ I am exempt under Sec. mumB & P C for this rea
APPLIANCESRESIDENTIAL
JOB DESCRIIPHON
J V lF—
PANELSLi
701-1000 AMPS
OVER1000AMPS
SQ. FT. FLOOR AREA
$/ .FT.
'
SIGNS ELECTRICAL
SPSCIALCIRCUIT/M15C
?EMP METN20RPOLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCHESHXTURES
_2VALDATL
,[tea 0.-
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPECONSTRIICTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC.CROUP
RFS. UNITS
FLOOD ZONE
APN
PERMIT ISSUANCE
'
ALTER -DRAIN & VENT -WATER
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
- RECEIPT If
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a certificate of consent to selPersure, ora
cedifimieofWorker Compensationlmurenceoracertlfiedwpythermf(Sec.
3800, Tab G
Policy N
FD(1VRES PER 7RNx
SCHOOL TAX Y_ N_
RECEIPC #
GAS
GA EA
PARK FEE Y N
RECEIPT #
Com any
GAS EA. SYSTEM -OVER 4 (EA) �
BUILDING DIVISION FEES
[PCentified copy is hereby th the city
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Tfhissectien need not be completed If the permit b forme hundred dollars
(8100)orlem.)
I certifythat k the performance of the work (orwhlchthla permit is Issued,
I shall not employ any person in any manner an as to become subject to the
Workens'Coerpensatton Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers' Campereation provisions of the Labor
Code, you most forthwith merely with such provisions or this permit shall he
deemed revoked.
CONSTRUCTION LENDING AGENCY
IhercbyafBrm that there is a comtmctlon lending agency for the perform
once of the work for which that permit is Issued (Sec. 3097CivC)
, , .
Larder'. Name
Lenders Address
I cortifythatl have readthuapplUllonand statethatthe above Information
Is correct.I ugree to comply with allcity and county ordinances and state laws
relating to building construction, and hereby authotlae representatives of this
city to enterupon the above-mentioned property for Inspection purposes.
(WO agree to cave, indemnify and keep harmless the City of Cupertino
against liabilities, judgments, costs and expenses which may In anywayaccrue
against said City In consequence of the granting of this permit
"•—F/J)
GREASEANDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date ReCCI f#
GRFASETRAP
SEWFA-SANITARY-STORM EA 2lsOFL
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N_
PAID
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMEESQFT.
TOTAL:
BUI DING FEE
-
SEISMIC FEE
t
TOTAL: -
EI-ECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTER ORADDTO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING T (OVER t0,OD0 CFM)
CONSTRUCTION TAX
suture of Applicant/Contractor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant rnfuture building occupant store -LOSU. die hazardous
metertal as defined by the Cupertino Municipal Code, Chapter 9.17, and the
Healthand SafetyCode Secilm MQ2(a)?
rj Yes MN.
Will the applicant or future building occupant use equipment or devices
which emit haeardeuair contaminants as defined by the Bay Area Air
Quality Management District?
Yes M No
have read the han—arm materials requirements under Chapter 6.95 of
the California Health&Safety Code, Sectiow 25505, 25533 and 25534. I
understand that if the building does not currently have a tenant, that It la my
rnponslbs ityce of a Elytheof cof thecupa requirements which most be met
prior to to et Certificate of Occupancy.
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UMT(TO 100,000 BTU)
Date Rete[ t#
HEATING UNIT (OVER 10),000 BTU)
TOTAL:
`
Y / ,
�
VENTILATION FAN (SINGLE RFSID)
ISSU DATE
Ns
j2UA
-
MA 1 Q Mioi
MA w (f p
IItiAa Crl� j!-�
�sy
a1AA��rs Cal \\`h�0'1
ISSUED D
BOILER -COMP PHP OR I00,M BTU)
BOILER -COMP 100,000 BTU)
NEW RESIDENTIAL MECH. SQ1,7
Owner or authodzeda agent Date
R
IL)TAL:
OFFICE COPY