22176APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Building Address:
PERMIT NO. 217 6
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CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BURAINGELECTRICALPLUMBINC-MECHANICAL
Ccmmcmr'I'rdcme:L(e.No:
JaL, ` e
CATEGORY
CONTROL Y
imet/Englexan Lie No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
25 1:1 1:1❑
PFRhBTISSUANCE
LICENBED CONTRACTOR'S DECLARATION
I herebyeffirmthat lamlicensed under powisionsof Chaptcr9(comment,
Ingwlth5 iun7000)of DtWtlon3ofthe Rusineas nd PmfesslonsC„ode, and my
Breve l.In fuR and effect. }` Z
License Claes LieY 31�6�1Y
Date Contredar J'f1C NUPTO200AMPS1C�
APPLIANCES -RESIDENTIAL
JOB DESCRIPTION
PANELS
X11"1000 AMPS
ARCHITECTS DECLARATION
I understand my plane shall be used as public record..
OVER1000AMPS
S/Q,`FT$/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
OWNER -BUILDER DECLARATION
I herebya(firmthat I amexempt from the Contractors License Law for the
Vi
SPECIALCB(CUIT/MLSC
gFMp MEFC[t ORIOLE INST.
POWER DEVICES DTE
(ollowmg reaaon.(Sectlon 70315, BusInenand Prolessmns Cade: Mydty or
oountywhichrequlresaper ttommtmL%iater,impmve,de=10h,ormpair
anystmcture prior to its L+eamme, also requlre.theappBant forsuch permitto
file a signed statement that he is licensed pursuant to the provisions of the
Q
�% pf
1e9r f% su 4
SWMMING POOL ELECTRIC
OU71E1SBWI'ICI IF_SF[%'1'URF_S
Contractors License Law (Chapter 9(commencing with Section 7000) of Divi-
Men3 oflhe Buslnessand ProfasalonsCode) orthat he is exempttherefromand
the basis for the alleged exemption. Any violation of Stolon 703IS by any
applicant fora permit subjects the applicant to a civil penalty of not more than
VALUATION
I C�
s'
,
five hundred dollars (SM.
❑I, as owner of the property, or my employees with wages as their sole
NEW RESIDENTIAL ELECTR SQFf.
STORIES
TYPECONSTRUCTION
compensetlon, will do the work and the structure is not Intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractor's License Law
does not apply to an owner of property who build& or lmprwes thereon and
whodeassuchworkhlmself orthrough hisawnempluyees, provided thatsuch
OCC.GROUP
RES. UNITS
Improvements are not Intended oroffered for sale. If, however, thebuilding or
TOTAL:
Improvement issold within oneyearofcompldmn, the owner-builderwin have
l}Ir�urden of proving that he did not build or improve for purpose ofsale.).
LJ I, as owner of the property, am exct..Mly ruse -dug with licensed
contncton to construct the project (Sec 70K Business and Profe edus Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
pFJ(MI.I. LSSUANCE
The Contractor's License Law does net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p4ojects with a
cgR[Lador(e)ecensed pursuant to the Contractor's License Law.
LII am exempt under Sec. B & P C for this reason
ALTER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y N_
RECEIPTY
Owner - Date
WORKPLAN I haw a cSATIDN DECLARATION
❑1 hereby affirm that I have o imumne of consent to opythe ref or s
3800, abC.Workers'Compevatianlneuancearaartifkd oopythereof pec.
3800, Lab CJ
Policyp
F7)CNRE9- PER TRAP
SCI{OOL TAX Y_ N_
RECEIPT Y
CAS EA.SYSFFAI-t INCd OUTLETS
PARK FTE Y N
RECEPT a
GAS FA. SYSTEM -OVER 4 (EA)
Com any �
BUILDING DIVISION FE[S
Certified copy ts hereby ththe city
❑ Certified copy ts flied with the city Inspection division.
CREASE/WDUSTRL WASTE IFITFRCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(TMasection need not becompided if the permit bforom hundred dollars
SEWER -SANITARY -STORM EA. 200FC.
Date Recei I#
WATER I-fEAT'FRw/veNT/ELEcrn
ENERGY FEE Y N
($lEB)arteea')
I certify that In the pedormanm of the work forwhlch this permit I. Issued,
WATER SYSTEM/TREATING'
I shag not employ any person In any manner so as to become subject to the
Workers' Compensation Lawsof California. Date
PAID
Applicant
NOTICE TO APPLICANT. If, ager making t his CertBl-m of Exemptlon,you
should become subject to the Worken'Comperuatlon provlamne of the Labor
Dale Reeel l#
NEW RESIDENTIAL ELMS. _SQ.Ff.
TOTAL:
DING
100deemed
Code, you reset forthwith comply with such provlsiov or this permit shall be
revoked.
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirmthat there is a construction lending agency for the perform-
ance of the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lander'.Addre..
I mAifythatl have madthlaappbatmn ami tlatethattheabove Infomatlan
umrrect.I agreetocomptywhh all cityand countyordmancesand ctatelaws
TOTAL:
ELECTRICFEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ielating to building construction, and hereby authodu representatives of this
city to enter upon the above-menliovd property for Inspection purposes.
(We) agree to rove, Indemnify an d keep harmless the City of Cu portion
against liabilities, judgerents,co#s and expenses which may in anywayaceme
tJ ALTE40RADDTOMECH.
Date ReCe1P[#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL'
age tyro n nae grantmgufml.permL
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
�gw of Appllant/Coma a Date
EXHAUST Hoop n+/Duca
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 9.IZ and the
Flealth and Safdy Cade Section 25532(a)7
❑ Yee MN.
HFATING UNIT GO 100,000 BM
Date ReceI t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Will the applicant or future building ocropant use equipment or devices
which cmR harardous air oantacumntsaselefined bythe Bay Area Am
Quality Management District?Ca{B®
Yea No
GI
a`i9
BOILEI4-COMP p}{PDR 100,IXgBM
BOILER-COMP(OVER 100,000 BTU)
_
iuveread the hara esus materials requirementsunder Chapterti.95 of
the California Health &Safey Code, Sect Lav 25505,25533 and 25534. 1
u ndereta od that if the building does not currently have a tenant, that it is my
MAY /ly '}
Q
'19 1901
NEW RESIDENTIAL MECI-1 SQ.FL
responsibility to notify the occupant of the requirements which must be met
prior to issuance of a Certificate of Ooiu pa nry.'
s
BY:
Owneror authodud agent DateISSUED
TOTAL:
OFFICE COPY