22444 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro en Identification PER1 .MIT NO.
Build Ing Add mar. 22444
a� Ad,
era one:
1�✓/L�S a CITY OF CUPERTINO4BUILDINGDIVISION
can Na In
APPLICATION /PERMIT
C=
s BU[LDINGELECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROE Mrp�
Arehltet/Englnear, 1 No: _ l
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE - 1:1_ ID [D]LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commene APIUANCESRESIDENTIAL JOB DESCRIPHON
Ingwlth Se on7000)of Didsion3ofthe Busineasand PrefeadonsCade,and my
license bin fair rax ndtfect PANELS �
License Cl a LIC
.,
Date_��� ContntorUP TO 2DO AWS D
ARCHITECT DECLARATION X11-IOWAMPS
Oa O I understand my plant scull be used as public mcomla OVER 1 Wil AMPS SQ,FT.FLOOR AREA f/SQ.FT.
Ez Licensed Professional SIGNSELECIRICAL / b' �!
�<<QE OWNER-BUILDER DECLARATION SIrECIALCR2CUTf/MI.SC �.DL r
z t"' Iherebyaffirmthatl amesempt from the Contractor's License law for the
(olbwing reasen.(Setion 7WlS,Basins.and Professions Code:Any or 1 , E R
O TEMP.METER ORI'OLE INSI'. v
p� countywhich rcqulresapemdttomrubuct,alter,impmve,demolbh,arrepalr
1 < anystm=m prlorto its bustance,alsorequireetheappliant forsuch permit to POWER DEVICESWVP
K V file a signed statement that he is Named pursuant to the provident of the /}
3 to Contactor'.License Law(Chapter 9(mmmencing with Sectlon 7000)of Divi- SWIMMING POOL ELECTING `Z
l„�0a pon3ofthe Bupneseand Prate mCade)orthathebemmpttherefmmand O VAON Q
the basis for the alleged exemption. Any violation of Section 70115 by any
✓a{ applicant fora permit subjects the applicant to a civil penalty of sea moa than OUILETSSWITC}ffSFIXITIRFS
live hundred delta.WB I. NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employees with wages as their sole SIDW TYPE CONSTRUCTION
compensation,will do the work,and the structure is not Intended or offered for
Osale(Sec.7046,Business and Professions Code:The Contractors Llceme Law
�'$ don not apply to a,owner of property who Wilds or improves thereon,and OCC.CROIIP RES.UNITS
who doessuchwork himself or through Msown employees,provided that such
Improvements are not intended orof(ered for sale.If,however,thebullding or TOTAL;
Improvementissold w)ihlnomyearo(comple fomtheowner-bulderwcli have
tl(ij?urden of proving that he did net build or Improve for purpose ofale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ I,as owner of the property,am exclusively contracting with Ilrenaed PERMIT ISSUANCE
contratan to comtmct the project(Sea 70K Business and Professions Code:
The Contractor'.License Law don not apply to an owner a property who ALTER-DRAM&VENT-WATER(EA)
halide or Improves thereon,and who conr.ats for such p♦oje to with a FEE SUMMARY
cgg(ptor(a)Ilansed pursuant to the Contradori License Law. BACK FLAW PROTECT.DEVICE
1_l l am.exempt under Sec. B h P C for this reason
?O�ne, Data DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y N—
WORKMAN COMPENSATION DECLARATION RFLEBT M
hereby&films that 1 have a ceeHB ctu,of consent to self-seam,or a FDtTLfRFS PER TRAP SCHOOL TAX Y N
RECEIPT I
ab C.) GAS EA.SYSTEM-1 INCAOtTILETS PARKFEE Y_ NY - RECEIPT S
CAS EA.SYSTEM-OOVER MAI Com any � BUILDING DIVISION FEES
ECertified copy 9 hereby furniabed. GREASE/WDUSTRL WASTEINTFACFPTOR PLANCHECK FEE
FICertWed copy Is filed with the city inspection dlvipan. �.�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID 4.,2?-V
COMPENSATION INSURANCE SEWER-BANTCARY-STORM EA 2WFT. Date Recei t#
(TMssection need not be completed lf the permit Existent hundred dollars
($100)orlea) WATER HEATER W/VENT/ELFCTR ENERGY FEE Y_ N_
I atlfytha[a the performance of the work forwhirh this permit is Issued,
I shag not employ any person In any manner sem to become objet to the WATER SYSTEM/TREATING
Workeo'Compemattnn Law..(California.Data
PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become sublet to the Worke.'Compematlon provbiom.(the Labor TOTAL:
N Cods,you mu at forthwith comply wlthsuch prmbfimamthis permit shall be 13UILDING FEE
I
LU j deemed revoked.
fil CONSTRUCTION LENDINGAGENCY SEISMIC FEE
IL C Ihfthe orkfo wthere bacomwctlon owed
f3ng3 g7,Civ. the perform TOTAL: ELECTRIC FEE
� Z an of Name PLUMBING FEE
F Lenders Add.. QTY. MECHANICAL PERMIT FEE
IL MECHANICAL FEE `
O W Iadl.Iagretocomplywappinlonanduntyardirecessadgation
telaws
1 Iscorrect.building complywith all ndcityand heray..thmordaanasanti pat slaw. PERMIT LS5l1ANCE FEES P/11D:�,I / ✓��s.a
} y relatingoenteru Pon t constmctian,ardherebyrtyorinrepresenta0poses. b �7
F Z city toenteree to the above-mentioned propetyfor mlesste Ck purposes. ALTEROR ADD TOMECH. Date Reeei t#
(We)agree to save,bdemnlfy an d keep mien the in a of pe
against @les,pdgmena - p dee x hlch nay In any aya a AIR HANDLING UNIT(f010,000 CFM) SUBTOTAL:
.gal dCity emery. he M this permit
S AIR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTION TAX
hl
Sig re p n on a or ate EXHAUSTHOOD(w/DIk I CONSTRUCTION TAX PAID:
HA R S MATERIALS DISCLOSU E
Iltheapplant lure building occupant store or handle a,cardoua HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code sr�Section 75532(a)? HEATING UNIT(OVER 100,000 BTU), TOTAL:
Yes 1I No
Will the applicant or forms building occupant use equipment or devices VENTILATION PAN(SINGLE REAL)) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lhy Management District? BOILER-COMP OEM OR 100,000 BTU)
1, Yea ❑No D
I cove read the hazardous materials requirements under Chapter 6.95 of BOILER.COMP(OVER 100,000 BTU)
the California Health I,SafetyCode,Sections 75505,75537 and 755M. I �s ,ew
understand that lithe building does not comently have.tenant,thalll b my NEW RESIDENTIAL MECH. SQI-7 (1e p V OMYO�
r.ponslbllity to orally the occupant of the regd.ments which must be teat c�
prior to Issuance of a Certificate of Occupancy. I1�, ��(/g/�
Ownermauthmixcd agent Data ISSUED gy;�-aU `(� LJ
TOTAL:
OFFICE COPY