22043 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project identification PERMIT NO.
Building Addresa: 22043
CITY OF CUPER NOBUILDING DIVISION
=-
s"• / u m APPLICATION / PERMIT L 1
BUILDINGS.ECnUCALPLUMBINC-MECHAMEGX
CAL CATEGORY CONTROL
rehire / glncer. le.No:
QTY ELECTRICPERMIT FEE BUILDING
/PERMITINFO
Address I PERMIT ISSUANCE I ,�1 (� ® i�/p
LICENSED CONTRACTOR'S DECLARATION ��I���III
I hereby.
am licensed under ptovlslansorChapur9(.sn APPLIANCES-RESIDENfIAL � rnp p¢-urt.rtca
tngwlth&dton7000)of DlvlNon3oft,he Businnsand ProreulonsCode,andmy, \r1lTi, ---,)'
licese nis In full( e and effLS G -�`ect. `'/ PANE
License Ch LIc.N
ConmactoFUPT02DOAMPS14Civ�j-L�l�j
ARCHITECTSd As public
coni OVERI0
00 ]senders, my pbmeha0&used upub0c reouNe OVER 1000 AMT'S SQ.FT.FLOOR AREA f/SQ.FT.
Licensed professional SIGNSELECTRICAL
G
OWNER-BUILDER DECLARATION 5['ECGLCIRCUIT/MLSC
Zs. I hereby afOrmtlat I am exempt(mmthe Cont factors License law for the
p following recto..(Section 7011.5,Bu.iness and Professions Code:Any city or
OZ TEMP.METER ORIOLE INST.
r ceuntywhkh rcquirnapertnit to construct,alter,improve,demalkh.orrepalr
anystmmmpdorwibiwamc almrequbestheappb=tf¢suchpermltfo POWER DEVICES
Ole a signed statement that he is licensed pursuant to the provisions of the
3w Contractors License law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC .
OJ sion3oflhe Buslnessand Pm(eulamCcin)mIhat he k exempttherefromand VALUATION
Ef ...777 the basis for the alleged exemptinn. Any violation of Section 70115 by any �
< appllnntin's pema.ubjects the applicant to a civil penalty ofnat more ` /h O than OUTLETSSWITOHESSXT'URFS ®J V o
five hundred dollars(4500).
NEW RESIDENTIAL ELFGTR
.n ❑Laaowner wll ochehe Looperty,or myand
employees Inwithwagn as feted for �'�• STORIES TYPE CONSTRUCTION
com(Sec,7 44,wllldothework.and icus,Code:
Th not Intended or offered(or
q sae snot appy to ainow ami f pmpclom Code:The or imp ct ma Llceme law
$�
does not apply loan ownerorthrouhwho Wilds orlmproovidedreory and OCC.GROUP RES.UNITS
EE whodonsuchworkrIntendedoswghedown employees,
enmr,theedthatwch
improvementsseenot Intended earofm pidioe.t h nee gthe erildingor
ve TOT
improvement baold withinoneyearo(complctloryfhc ewnervbu0derwlllhave
theekrden or proving that he did not build or lmprove(m purpose ofule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed 1'FRMI.I.ISSUANCE e1
contractors to mostmct the project(Sec.70K Business and Professions Cade: 4
The ContvRor's License Taw does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA) _
Wilds or Improve.thereon, and who contracts for such plojects with a dea FEE SUMMARY
cq Tor(s)B¢nsed pursuant to the Contractor's License Law. RACY FLOW PROTECT.DEVICE
LI I am exempt under SB h P C for this renin
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECFEN
❑ by WORKMAN COMPENSATION DECLARATION FIXTURES-�.Rs IL SCHOOL 7A% Y_ N_
I hereaffirm that I have o I m mn of consent d spy theme ora '1 a RECER'T N
certifiL,b C.Workers'Compematlanlmurann¢acertllkd appy tbemo((&c. GAS EA.SYSTEM-1 INCA OUTLETS PARKFFE Y N
3600,Lab C.)
GAS EA.SYSTEM-OVERd(EA) RECEIPT M
X
CoCa BUILDING DIVISION FEES
edified copy is hereby te
Certified copy V filed withh the city
Wptttbn division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM F.A.2[XET Date Recei tN
Rhls¢ctlon need not&completed tithe permit V(¢orae hundred dollars
(Slw)I cartily that in the perlonconce,ofthe work for which this permit is Issued WATER HEATER W/VENT/ELEC7R ENERGYFEE Y N
I coal not employ any nems In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lwa of California.Date PAID
Q Z Applicant NEW RESIDENTIAL PLMB._SQ.FC. - Date Recei IN
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compemation provlskra o(fhe Labor TOTAL:
CC N Code,you must forthwith comply,with such pmvaiom orthis permit shall beBU G
W > deemed revoked. 1.
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE
IhembyafOrmthat there V a construction lending agenry(orthe perform TOTAL: ELECTRIC FEE 2
Z ance of the work"(or which this permit is Issued(Sec.3097,Civ.C.)
Lf O lenders Name PLUMBING FEE x,00
LL F Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE e
OW I¢rtilythatl have madthkappBceHon and Matethatthe above information meq.
CIL iamrrcct.l agreetocomply with all chy and county ordkanoesandsoulaws I PERMIT ISSUANCE � J_C FEES PAID:
N relating tobulidlegoumtmctlon,and herebyautharize represenuolvno(thk
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTO MECH.
— (We)agree to sew,Indemnify an d keep harmless the City of Cu pool. Date Receipt#
against liabilities,jadgmeM curt Pemex which Ray In anyway accrue AIR HANDLING UNIT CIO 10,010 CFM) SUBTOTAL:
Against said ym a nrth in offhle±rrtdt, AIR HANDLING UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
'Si-g6l§ps6fAp m/C ntia / Date FXFIALJST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI Id
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Coda Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL•
n Yn M No
Will theapplicentor future Wliding oavpact useequipment or devices VENTILATION FAN('INGLE RFSID) ISSUANCE DATE
which emit havardous air contamimrata as defined by the Bay Arca AU
Quality Management Di❑strict? BOILER-COMP DID'OR 100,000 BTU) ®q ram
. Ihave readlhehazardomomaterialsmquime nlsunder Chapter6.95o( BOILER-COMP(OVER 100,000 BTU) T_AM
the California Health A Safety Code,Sections 25505,25533 and 25536.I -mac.!
undesta ed that if thebulldingdonnof currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQXT �F�s}
resposslbllity to notify the occupant of the requirements which most W met APR
R j 619
prior to Issuance of a Certificate of Occupancy. vv
Ownerorauthorizedagent Date •+ (tea
TOTAL: ISSUED BY ; ,. 'i§��'a"-xc'x'
OFFICE COPY