22884APPLICANT TO FILL IN INFORMATION WITHIN RED LINES USE BALL POINT PEN ONLY
Building Protect Identification - -
Building Address:Cj/�ws-� - - '�.
PERMIT NO.
- 22884
nets arse: one:
APPLICA TION SUBMI I I A
"
CITY OF CUPERTINOLBUILDING DIVISION
APPLICATION / PERMIT
_
IN
M: LIc.No
C on a ame
CATEGORY
CONTROL M
•
-
rehited/ glneer, - Lie No:'
QTY. ELECTRICPERMIT FEE
BUILDING PERMITINFO
PERMITISSUANCE
Address: '-
❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby affirm that am licensed under provisions of Chapter c-
APPLIANC SSRFADENTIAL
JOB DESCRIPTION
PANELSLt.
ingwlth Se ion7000)ofDlvlslon3ofthe Bumnessand ProfeW a aan y
licenseIs In fuB force and effect
Class OContr
I
` _- gs l' i
Date
Dare Contractor
ARCHITE DECLARATION
I understand my plzre.hall be used as public reroMs.
` V tIV` / J 1
101-1000 AMPS
OVER]000AMPS -
`�Q•�'H-OOR ARS`
`�'�'
SIGNS ELECTRICAL
Licensed Professional -
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I herebyaffirtnlhat I amexempl fromthe Contudoes License Law fmthe
TEMP. METER OR POLE INST.
following mason. (Section 7031S, Business and Profession. Code: Any city or
cmntywhichrequiresaperadttommt d,aihr,impmve,demoli.h,orrepair
-
anystructurepdormitsissuance, also exquirestheapplicant fortuch permit to
file a signed statement that he is licensed pursuant to the pmvisioru of the
PGWER DEVICES
SWIMMING POOL ELECTRIC
Contractor'. License Law (Chapter 9 (commencing with Section 7000) of Divi-
sl.n3oftheBu.messandProfmss uCode)orthatheisexempttherefromand
VALUATION -
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant for a permit subjedsthe applicant to a civil penalty of not more than
OUTLETSSWITCHESFIXTURES
live hundred dollars %SOO).
FII, as owner of the property, or my employees with wages as their sole
compensation,willd.the work, and the.trucrom lsnat intended or offered for
NEW RESIDENTIAL ELECTR SQ.FT.
STORIES
TYPE CONSTRUCTION
sale (Sec. 7014 Business and Professors Code: The Contractors License Law
does not apply to an owner of property who builds or improves theren, and
who does such work himself or th rough his own employees, provided that such
OCC,GROUP
RES UNITS
TOTAL:
Improvements are not Intended oroRered forests. If, however, thebuilding or
Improvement issold Mthlnoneyearofcompletion,theowner-budderwlll have
the burden of proving that he did not build or improve for purpose of sale.).
IJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7040 Business and Profesdom, Code:
QTY, ." PLUMBING PERMIT FEE
FLOOD TONE
APN
PERMIT ISSUANCE as
The Comrector's License Law does not apply to an owner of property who
for such pipjee with a
s, and who ntndi ct
Wilds or improves thermm
cactor(s) licensed pursuant to the Contractor's License Law.
t I am exempt under Sec. B k P C for this reason
ALTER -DRAIN kVENT- WATER (EA)
FEE SUMMARY
BAC( FLOW PROTECT. DEVICE
-
DRAIN3FfOORROOF,AREA,COND.
SANITARY Y_ N_
RECEIPT a
Owner Date
WORKMAN COMPENSATION DECLARATIONEg-
I hereby affirm that I have a certificate of consent to sel6imuce, ora
ppRx
FD(TUR__RECEIPT
SCHOOL TAX Y N_
M -
GAS EA. SYSTEM -1 IN'CAOUTLETS 3
PARK FEE Y_ N
c Ifirate o(Workera'Comperwtlonlmurance ora certified ropythereof (Sec.
3500, Lab C.7
CP�z9
Policy #.
Com any
GAS EA.
DING DIV
BUILDING DIVISION FEES
(=feertmedcopy ishereby furnished.PLANCHECKFEE
chilled copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
GREASE TRAP
- CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER-SAMTARY-STORM EA.2f10I7
COMPENSATION INSURANCE
(TMssee ion need not be completed lithe permit is forone hundred dollars
(6100)orlessJ-
I certify that N the performance of the work for which this permit is Issued,
I shall not employ any person In any nanner so as to become subject to the
Workam'Compensation UwsofCallfomia. Data
Applicant
NOTTCETOAPPLICANT:ILaRer.kilothi.Certificate.(Exempti.,you
should become subpdtothe Workees' Compensation provisions of the Labor
Date Recei I#
WATER BEATER W/VENT/fl.ECIR
ENERGY FEE Y_ N_
-
PAID
Date Remi t#
WATER SYSTEM/TREATING
-
NEWRFSIDENTIALPLMB. SQ.FT. -
TOTAL:
_
NG FEE
Code, you must forthwith comply with such provblom or this permit shall be
_
SEISMIC FEE
deemed revoked.
CONSTRUCTION LENDING AGENCY
TOTAL:
ELECTRIC FEE
I hereby afflrenthat there is a mrutrudi.n lending agency for the perform-
anmofthew.rkforwhlchthb permit baiasued(Sec.3097,Civ.Cd
Lenderb Name.'MECHANICAL
Lender's Addreea
PLUMBING FEE
PERMIT FEE
MECHANICAL FEE
I reit ify that I have read t his a ppBcatlon a M state th at the above information
ismrrect. l agrecto comply with all cityand rountyordinadces and mate laws
relatiegtobuilding mr�atrudlon, and rebya Iumse resentatives of this
city to enter upon the above -menti. Idfors then purposes.
(We) agree to ,Indemnify dices rmie teCity .(Cupertino
agaWtllabi@tse dgmenb, cors ed exile ewhl yin anywayacerue
zgauutsaid Ci in ronseque (the gra og of i m`It.
PERMIT ISSUANCE
FEES PAID:
-
ALTFRORADDTOMECH.
Date ''ReceiFt#
AIR HANDLING UNIT CFO
lT
SUBTOTAL:
-
AIR HANDLING UNIT (OVER 10,0D0 CFM)
CONSTRUCTION TAX
EXHAUSTHDOD(W/DUCT)
CONSTRUCTION TAX PAID:
reof Appllant/Con odor• Dae
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant.rfuturebulldingompant store or handle hazardous
HEATING UNIT (TO 100,000 W1!)
,Date ReCel t#..
material as defined by the Cupertino Municipal Code, Cha Ater 9.11, and the
Health and Safety Code Section 25532(a)7
[] ,,
Yes gNo
Willthe applicant offuture Wildingoccvpantuse equipment ordevices
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN (SINGLE RESID)
'
ISSN®ATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lity Management Q�ajrid7
Yas Ira27Cj No
have read the hoz ous malerlalerequl n oder apter6.95of
OCT' 7 '
I. i U I�gl,
BOILER -COMP OTIP OR 100,000 BTU)
BORER-COMP(OVIIi 100,000 BTU)
,
the California Health Is fety Code,Sedio 2550, 533 25534.1
understandthatlfth ilding does not eptly vea dent, that It is my
responsibility to n the occupant f i requ nl I<h must be met
-
City Of, CUQBI'hlPa • '
NEW RESIDENTIAL MECH. SQ.FT.
prior to antt aCertifkate of ancy.
,
Pte
ISSUEDBY.
mer or out red agent
TOTAL:
OFFICE COPY