22540 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building AddBuildingProm Identification
- PERMITNO.
LIZ Crtt— cT !l Rota 22540
wnsre aces: oue: CATIONSUBM11TALDAlu
M ,6 y -•3 - CITY OF CUPERTINO-BUILDING DIVISIONr��—��/
cmtrsdJnr'&N me: LI.No: APPLICATION / PERMIT - '
F1.5e n r BURDINGELEC'fRICALPLUMBINGMECHAMCAl CATEGORY CONTROL#
Architect/Engineer.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
Lkenx ClanLICENSED C1cOpN�TMRAJRJTO/R'SDECON PERM- TISSUANCE t-Z_
�X't'—
I hereby
lacethat
I d nso(Chapter9(commm APPLIANCES-RESIDENTIAL JO DESCRBDs9
T1
N
thSmthD00)ofDivs[or3ofthe BusinexandlmfmlonsCode,and my
lke.sclsi.flfa�¢ d( PANELS
Date �qJ--_Cordranor UP IOOBAMT'S
�'MCNITECTS DECLARATION
p�p�++mz I understand my plans shall be used as public records. OVER10DOAMPS SQ.Fr.FLOOR AREA $/SQ.FT.
k o Licensed Professional SIGNS ELECTRICAL (T�/.J(,
<< OWNER-BUILDER DECLARATION ��D�
Ci a a SPECIAL CRtCUIT/MLSC
Iherebya((IrmtFutlam,exempt tromlhe Contractor's Lkxnselaw for the
pp Following remora.(Section 7031.5,Business and Profession Code:Any city or ^
O 2 r TEMP.META{ORPoLE INST. psi•
� ceuntywhich requlreea perMttocorutvat,site#improve,dertnlish,orrcpair
anyswclure prlortoitabsuance;also requbesthe applicant far such perodl to
thea signed statement that he b licensed pursuant to the provisions of the )'OWER DEVICES
Ole Contndoe License Law(Chapter9(commencing with Section ARC)of Divi- ON
F,30 sion3ofthe BuWm and Pro(mbnsCode)orthH he beump[therefromand SWIMMING POOL ELECTRIC
S^ the basis for the alleged exemption. Any vlolallon of Section 70)IS by any OI7ILETSSWITCHESFIXTURES
O<SA applicant for a permit&ubjectsthe applicant to a civil penalty of nor room than t
live hundred dollars($500), NEW RESIDENTIAL ELECTR_SQ.Fr. 57OW65 TYPECONSTRUCTION
�n ❑1,as owner of the property,or my employees with wages as their sale
c mpensatlon,will clothe work,andthestrodure laretintandedor offeredfor
Osale(Sec 70K Business ami Pro(mions Code:The Contradoes Llcemde Lw
$ does not apply to an owner of property who Wilde or Improves thereon,and OCC.GROIRa RES ITMTS '
0. who does suchwork himself or through Msown employees,provided that such
Improvemcrosarenmintendedorofferedfwrn If,however,the building or TOTAL: Z
Improvement bwld Mthlnomyearo(completioNtheowner-W RderwgI have
t4Liiurdert of proving that he did nor build or Improve for purpose ofsals.). QTy. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE-
contractors to comtrud the project(Sec.7614 Basin.and Pro(mions Code: ,U
The Contmn does License Law donot apply to an owner of property who
Wilde or Improves thereon,and who contracts for such p(ojects with a ALIII6DRAINA VENT-WATER IEA)
cgV. ec cto*1 licensed pursuant to the Contractor's License Law. .AIX FLOW PROTECTDEVICE FEE SUMMARY
L_1I am exempt under SB k P C for this ream, .
OUTS I Up FEES
DRAINS.FLOOR ROOF,ARRA,GOND. SANITARY Y N
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATIONFIXTURES.PER TRAP CoA SCHOOL TAX Y N
❑I hereby.ri mt that 1 have a a c of consent to self-Insure,ora !/ RECEIPT M
martiBmolWorken'Comns
peadonlnsuInsurance oracedlficd mpythereof(See. GAS EA SYSTEMt INGOUTLETS<OUTLETS PARKFEE Y N
3800.Lab CJ
Polity p RECEIF r 4
GAS EA.SYSTEM-OVER!(EA)
Com any BUILDING DIVISION FEES '
Caddied copy is herebyfurnished.the city GREASE/MDUSIRL WASTE INTERCEPTOR PLANC14ECKFEE
Candied copy ls Ned with the city Inspection division.
CERTIFICATE OF EXEMPFION FROM WOR KERB' GRE-ASETRAP PAID
COMPENSATION INSURANCE BEwER,ytM.1.ARy-yTORM EA pBF1. Date Recei t#
(rMssectlon need not be completed lithe permit lsfor one hundred dollars
($IW)ne lm) WATER BEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I codify that In the performance of thework(orwhlch this permit ie Issued,
I shall not employ any person In any manner w as to became subject to the WATER SYSTEM/IREA7ING
Workeri Compensation Lws of Calltorols.Data PAID
C' Z Applicant NEW RESIDENTIAL PLMB SQFf Date Recel t#
Z O NOTICETO APPLICANT.$after mekl.g this Certificate of Exemption,you
"Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this permit&hall be BUILDING ,0
deemed revoked.
LU ' CONSTRUCTION LENDING AGENCY SEISMIC FEE 'iD
CL I hereby afBrtnthat there b a mrutrudlon landingagency forthe perforn, TOTAL: /m ELECTRIC FEE
O Lend1�x
M Z ance of the work far which this permit is issued(Sec.3097,Civ.C.) ��vv
V er&NamePLUMBING FEE _
LL I– Lender's Addrcu QTY. MECHANICAL PERMIT FEEMECHANICAL FEE
OW Iced lty that l have read this application and dale that the abovein(orrna0on
1 lacrosed.lagrcemcomply with all dtyand county ordinance and nate laws ITISSUANCE FEES PAID:
relatingtob itdingmmnlrodlogandherebyauth.r .prexntatNnofthis
f" N city to enter upon the above-rreddoned property for inspection purposes. AL ORADDTOMECH.
2 (We)agree to save,Inde an d ep harad-the City a(Cupertino Date Reeeipt#
V against liabilities,jai b de and pensee whlch.yCin%nywayamme AIRHA LING UNIT(rO IO,ODOCFM) - SUBTOTAL:
against said C 1 ance of t grmdng W this permit.
n AIRHAND G UNIT(OVER 10,010CFM) CONSTRUCTION TAX
SignaturefAppl t/ out xct& Data EXHAUSTHOO (W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or tuition building occupant atom or handle hacardous HEATING UNIT an'"BIA) Date Recel t#
material as defined by the Cupertino Munidpal Code,Chapter 9.17,and the
Health and Safety CoM .cti.a 75537(.)7 HEATING UNIT(OVER ,000 BTU) TOTAL:
❑Yea I]j"No
Will the appllant tore bctldfng occupant use equipment or devices VENTILATION FAN(SINGRESID) I65Ap11{�E DATE
which emit havard...ab mntamlnsnb a defined by the Bay Area Ab r!V 1�
Quality Managementmss sit BORER-('AMP OHPOR 100, TN
T1
Yea $o No YT N
Th ave read the hanr�ous materials requirements under Chapter6.95 of BORER{OMP(OVER 100,000 BTU) A 5 1&�
the California Kea llhh Safety Co de, Io ns75505,25ST3and7:534.1 fi
understand that it t'Iu,& lding doe otmrtentlyhavo atenanq thatitb my NEWRESIDENTIALMECH. .Fr
responsibility to notify eomup of the requirements which must be mat (ajW wL Aswes�i�' a
priori. nificate Occvpanry. W P�{��
Y• Cil
Owner or authodud agent Data 'TOTAL: ISSUED BY:
OFFICE COPY