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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Buiidin Project Identification -
Building Address:
I!F:RhRT NO.
22918
L
canna :
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION 1 PERMIT
BUILDINGMECTRICALPLUMBING-MECIiANICAL
)0�2� Ly
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C° ractor.Name: /1 ic.No:
Ll
CATEGORY
CONTROL
Architect/Engineer. Lk. No:
QTY ELECTRIC PERMIT FEE
'BUILDING PERMIT INFO
,
Address:
PERhBTI55UANCE "
-❑ ❑ '
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commeno-
APPLIANCESREADENTIAL
JOB DESCRIPTION
Ingwith5ect1on7000)of DivIs ct. ofthe BueinnaandlarmfeaslonsCode,and my
license b In fia a end effect.
4 PANELS
d.A.�` <l,4.! -S L46-47
��'' // T "O''Tv�C"iG� 7J
�J-F
Licen Chea Llcp
Date Coniractor
777
UP TO 2DO ANTS
T iN(T s !
OR.taJar�'Ia¢/
••$y. C. 4'I64'Te Ii
201 -IOW AMPS
OVER1000AMPS
SQ. FT: FLOOR AREA
� E D I N
$/SQ. Fl. -
ARCHITECT DE public
I undemtand my plans shall be used a public i rob..
Licensed Professional -
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby afBrvthat I am exempt from the Contractors License Law forthe
P T R
,
TEMP. METER OR POLE INST.
^wx
POWER DEVICES - DATE
following reason. (Section 7031.5, Business and Professions Code: Any city or
cuntywhich requiresa permit tororutmct, alter, improve, derrulish,orrepair
anystructure priertoits issuance,ahorequiresthe appliamfor such per itto
file a signed statement that he I. It ... d pursuant to the provisions of the
SWIMMING IDOL ELECTRIC
OUILETSSWITCHFSFLXTURES'
Contractor's License Law (Chapter 9(mmmenetg with Section 7000) of Divi-
cion 3ofthe Buslnne end Profraluni Code) ortbat bets exempttherefromand
the basis forthe alleged exemption. Any violation of Section 7WIS by any
applicant fora permit aubjeatsthe applicant toacivil penalty o(nnl rare than
/ VALUATION
ISoo
NEW RESIDENTIAL ELECTR SQ.FT.
five hundred dollars ($500).
F11, as owner of the property, or my employees with wages as their sole
STOKES
TYPE CONSTRUCTION
romp .... tlou, will do the work and theatructure Is mal, intended or offered for
sale (Sec. 7094, Business and Professions Code: The Contractors License Law
,
-
does not apply to an owner of property who builds or improves thereon, and
who dcea .uch work himselfor through his own employeea, provided that such
OCC.GROUP
RFS. UNITS
Improvements are not Intended oroffered forsale. If, hmvever,thebuildingor
TOT
,
Improvement hsold within oneyearedcompletion,tbe owner-bullderwill have
Ikeburden of proving that he dM net build or lmprmo for purpose of sale.).
IJ L as owner of the property, am exclusively comr—i., with 14xneed
cornu toia to ronaeult the project (See 7094, Business and Profeaslo s Code:
.
QTY, ,PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who
Wilds or Improves thereon, and who contracts for such p(ejects with a
�q➢IT�cto(.) licensed pursuant to the Cutnums. License Law.
LJ I am exempt under Sec B & P C for this reason
PETER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
- -
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y— N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a ceM(late of consent to self -Insure, ora
certificate ofWorken' Compensation Insurance or a certilled copy thereof (See.
3800, Lab C3
NIX'fURES PER TRAP
SCItOOL 7AX Y_ N_
RE-CEPT s
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N
'RELEB'fR
Policy a
Com any -
GAS EA. SYSTGI-OVER 4 (EA)
BUILDING DIVISION FEES
�CertlBed copy ereby furnished.
ropy la filed with the city Inspection division.
GREABE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
-
GREASE TRAP
CERTIFICATE OF D(EMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 2(1011'.
. COMPENSATION INSURANCE
(This section need not be completed If the permit 6for one hundred dollars
($100)or less.)
I certify that In the performance of thework forwhlch this permit is Existed,
Date Recel t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y_ N_
WATER SYSTEM/TRFATING
I .hall not employ any person In any manner so as to biome subject to the
Workeri Compensation Laws of California Date
PAID
NEW RESIDENTIAL PLMB. SQFT.
Applicant
Date Remi t#
. NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workers'Compenntlon provisions of the Labor
TOTAL:
-
BUILDING FEE
Code, you must forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL:
ELECTRIC FEE
(,
I hereby afflrnthat there h a construction lendlegagency forthe perform,
ance of the work for which this permit is Issued (Sec. 3097, CIv.C.)
Lender's Name
Lender's Address
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE .'
MECHANICAL FEE
I.Aifythat l have readthIs applimtionand aatethattheaboveinfomatlon
iscorred.I agreeto comply with all city and county ordinances and statelaws
PERMIT ISSUANCE
FEES PAID:
reldingmbuilding construction, and herebyeuth.ma representativesnfthis
citytoenterupontheabov mentioned property for impaction Purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cu portion
.gal s111 bWlie, gmants,usteand man which may In anywayacrme
-
ALTERORADDTOMECH.
Date Receipt#
PIR HANDLING UNIT (TO 10,000CFM)
SUBTOTAL:
agar m seque of granting of permit.
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
Ignamr of Applicant/C or Dat
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
' HAZAR9 US MATERIALS DISCLOSURE
Wlllthe appBant orjQNrebuilding occupant store or handle hazardous
—asna go
HEATING UMT(TO IW,000 BTU)
-
Datil Recei t#
material as defined bl,t a Cupertino Municipal Code, Chapter 9.12, and the
Health and Safety Code Sect" 25532(8)1
❑ Yes
Will theappllant oru1reW'Iding occupant use equipment or devices
HEATING UNIT (OVER 100,000 BTU)
_ TOTA
VENTILATION FAN (SINGLE RESIO)
p� {}
^ ISSP�AjSI(4%D1TE
which emit hazardous air contaminant... deflned by the Bay Area Air
nt
ality
I �Ihav reedsmee„Dahtus materials requirements under Chapter&95 of
,p Q -
1 n
OCT29J
I�1
BOILER -COMP 100,000 lly
BOILER -COMP (OVEt 1100,000 BiOR
the California Health&Safety Code, Sections25505,have a tend, that 1
understand that note rrentlyhaves that b
��--sa—��J
- CITY OF CUPEHTINO
NEW RESIDENTIAL MECFI. �.ET.
the ongdoea
met
6111ty to.f. the sof the requirements which must be met
notify which
V V
Prior
Prior seance ofa rtlBc Occvpan
L•l
ISSUED 6N
mer or authorise ant ate
TOTAL:
OFFICE COPY