22044APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project identification
Building AdO2Sg `
!►>�- /Y A
PERMIT NO.
22044
weer ante one.
L'pj r
CITY OF CUPERTINOBUILDING DIVISION
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBINGMECH LAICAL
l b! I
�j �
CATEGORY
CO LM
Architect/Engineer. Lic. Na
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
------
Address:
fes. 1:1 El❑'
L.�'
PERMIT ISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I herebysed usims..d fe hsptec9(cosrul
i cense iSeMon700Wof Divielon3°(the Businessandl'�fesNonaCode,and my
Lt.. le In tui c,11 , r /
Limns a UcN j� �
Date Contractor - L
APPLIANCES-RESIDENML
JOB DESCRIIPt1-7a0�Np �I�X
�•�`( CbVa'-
PANELS
LIE IQ 200AMPS
701.11X10 AMPS
ARCHITECPS DECLARATION
I understand my pare shall be used u public records.
OVERIOOOAMPS
SQ. FT. FLOOR AREA
$/SQ -FL.
SIGNS ELECTRICAL
Licensed Professional
_
OWNER -BUILDER DECLARATION
I hereby affirmthat I am exempt from the Contractor's License law for the
SIPFOIALCIiCUIT/MLSC
TEMP. METER OR POLE INST.
following reason. (Seelon 7011.5, Business and Profession, Code: Any city or
county which requires a permit locurotruct, alter improve, demolish, orreper
anystructure prior to its Issuance, also requires the applicant for such permit to
file a signed statement that he b licensed pursuant to the provblors of the
Contrador's Licwse Law (Chapter 9(comnencing with Section 7000) of DW6
sion3 ofthe Businesemd Proa
ftook Code) mthat heb exempi therefromand
the hasis for the alleged exemption. Any violation of Section 7m IS by any
applicant for a permit subjects the applicant to a dvll penalty of not namethan
POWER DEVICES
,
SWIMMING POOL ELECTRIC
OUTLE'ISSWITCFIFShTXTURES
VALUATION
Q
NEW RESIDENTIAL ELECTR SQFT.
flue hundred
ow e,of thepr.
I, as owner a( the a warky, or my employes with wages r iMtr wk
will do work,and the dureh nm Intended offend for
STORIES
TYPE CONSTRUCTION
.1. (Se,c,aapens7044,
sae (Sec appy Business
Business ima,C L
Cob The ctofsIhmrue law
f property
wosnotapply tomownel ofp f car rough who loss/dsorimprwesthereory and
to owner or trap
who himae his own employees, prothat
OCC.GROUP
RES UNTIE
amwork
dad oroffe theb gor
improvements am not Intended earofc forage.If,h er-g oder ldingve
Mprovement ,sold wlthlooneycarolcompldbrytheownm-bullderwW have
TOTAL:
the*rden of proving that he did not build or improve for purpose ofsale.).
as owner of the property, am exclusively contracting with licensed
omtracton ct
to construct the proje(Sec. 704y Business a ad Protections Code:
QTY. PLUMBING PERMIT FEE
FLOOD TONE
"N4
PERMIT ISSUANCE
The Contractors Like. Law does not apply to an owner of property who
s or Improves thereon, and who contracts (or such ptojem
m with a
cgB{rydorW licensed pursuant to the Contractor's Llcens Law.
Ll I am exempt under See B & P C for this reason
•
ALTER -DRAIN &VENT WATER (EA)build
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N '
RECEIPT N
OwnerDate
ORI ANCOMPENSATIONDECLARATION
L!frhpI)nURF&
ereby artless that I have o lmurane of consent to pythsure, ora
cortl,Lbof Workers'CompersaHonlmuranttorattklfkd cupylhereof(Sec.
3800, Lab CJ
Policy
PER TRAP
SCHOOLTAX Y N
RECEIPT N
GAS EA. SYSTEM-11NC4 OUTLETS
PARK FEE Y N
RECEIPT N
Y Cag;GAS
Com an
VER E
EA. SYSTEM -OVER 4 (A)
BUILDING DIVISION FEES
ertifind cupy b hereby himlahed,
OCekWed copy Is filed with the city inspection division.
GREA$E/WDUSIRL WASTE INTERCEPTOR
PLANCFIECIC ITE
GREASETRAP
CERTIFICATE OF UEM PTION FROM WORKERS'
PAID
SANITARY STORM EA 700FT
COMPENSATION INSURANCESKIVER
(This section need not be completed if the permit bloc ore hundred dollars
Date Re i t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y_ N_
PAID
(SILn)mh
I certifyfy that
t In the performance low
aunce o(the work (orwch lhle permit is ed,
I shall not employ any person In any nemor an as to become subject to the
Workers' Compemakon Laws of California. Date
WATER SYSTEM/TREATING
Applicant
NOTICETO APPLICANT: I, after making this Ceklfloa/e of Exemption, you
should become subject to the Workers'Comperwtlon provtalom of the Labor
NEWRESIDENTIALPLMB. SQ.FT.
Date Recet t#
TOTAL:
BUILDING FEE
s
Code, you must forthwith comply with such provialuns artists permit shall be
dined revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
O
Iherebyaffirm that them Is a construction lending agency for the pekomm
ance of the work forwhlch thin permit Is Issued pec. 3097, Civ. Q
Lender's Name
Lenders Add reea
I artily that I have read this application and elaM that/the above information
bcormot.I agree to complywith all chyand countyardinances and pate laws
TOTAL:
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building construction, and hereby aulhorlu representatives of this
city to enter upon the abovementlnned Propertyforlropectionpurposs.
e) agree save, Indemnify an d keep harmless the City of Cupertino
age tleb ,Judgmenh,"sand expenseswhlch nuyloanywayaccrue
ALTER OR ADD TO MFCH.
Dale Receipt#
AIR HANDLING UNIT (TO 10,0DO CFM)
SUBTOTAL'
ag mt sal it In con f the grant of Ws perrat.
e 4el/a
Y
AIR HANDLING UNIT (OVER IO,OOgCFM)
CONSTRUCTION TAX
SI core °f Applicant/Contractor e
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
-
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CIO 100,000 BTU)
Date Recei t#,
Will the applicant orfuture huiidingoccvpantstare or handle hazardous
materbl as defimd by the Cupertino Mu Ndpal Code, Chapter 9.17, and the
I lealth and Safety Cade Section 75532(a)7
❑ Yea No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
1
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DATE
Willthe zpplcanl °r turcbullding arvpantus equipment ordevlms
which emit haeardous air contaminants as defined by the Bay Area Alt
alhy Management Dbtrlct7
Yes No
PAIS)��jj
BOILER -COMP OHPOR 100,000 BTU)
BOILER-(DMP(OVEt 100,000 BTU)
ave read the hazardous roBlekals requirementsunder Chapter8.95 of
the Callfomis Health &SafetyCode, Sediom75505,75533 and 75534. 1
understand that ifthebuilding does not currently have amnant, that It b my
I^
/'1!-"
NEW RESIDENTIAL MECH. SQ.FT.
resporsibuity, to artily the occupant of the requirements which at be met
prior to lasuanre of a Certificate °f Occupancy.
rs�/1,
ISSUED BY, VI YrI V')[;++\KI.N�s
Ownercrauthokzedagent Date
TOTAL:
OFFICE COPY