22911 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Praia I Identification PERMITNO.
Building Address:
'Cleo . cakrA%pyr ;u 22911
wren eine:
RJAAws�0 Sr.C -QN14
CITY OF CUPERTINCL BUILDING DIVISION
• cantr or w� "L APPLICATION /PERMIT CLVn
BUI
LDING-ELECTEICALPLUMBINC-MECHANICAL 'CATEGORY CONTROL
Architect/Engineer. Lic,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrns
PERMITISSUANCE ❑ ❑ E]LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lamticeresed under provWonsof Chapter 9(..so APPLIANCESRESIDENI7AL JOB DESCIN'fION
wit
g
Inh Seaon
ti7f1f10)mf DlWalen3o(Ihe Buslneaeand feselonaCode,and my
irwft Ismfir dd(ect. PANELS
License Cb LIeR
Data C I Contractor
Aividall CTSDECLARATION OVER00AMI5
oZ ]understand my phnsehaB be used upubacremrda OVER 1000 AM[a5 i E E B .�FG7Rf�A7 A f/SQ.FT.
D ^^'.
Licensed l'sofemansl SIGNS ELECTRICAL _ ( ryry,� pp 1[�
OWNER-BUILDER DECLARATION - SPECLILCIRCUIT/MISC u� 1 U T 6.
1herebyafflrmthat l amexemptfromthe Contractor's License Law for the
pp following mum.(Section 7Pd1.5,Business and Profealans Code:Any city or
OZi. TF7dI'.METER ORIOLE[NST. ! Gr
F, =ntywanystmhlmpq tolap anceaco mqui ttheapflentfm ch,orretw
`'� any structure statement
It that he I.alermsed mluant to the providers,
of t e
ryG DAT
file a signed statement that he V Bansed pursuant a the proWlons of the IOVfFR DEVICES '
Ow Contractors License Law(Chapter 9(commencing with Section 7000)ofDivi.
�0 earloflheBusmenand ProfesdoreCode)arlhathebexemptlhere(romanA SWIMMING POOL ELECTRIC DVAOLUA
Gthe Weis for the alleged exemption. Any violation of Section 7041.5 by any OUTLET SSM"CHF5FLXTURFS
O appBant fora permit subjecatheappllcantto a civil penalty of not room than
R� five hundred dollars($500). NEW RESIDENTIAL ELECTR SQXT. STORIES TYPE CONSTRUCTION((((WWilililil �n ❑I,u owner of the property,or my employees with wages as their sale
compensation,will do the work and the structure Is not Intended or offered for
G sale(Sec.7044,Business and Pro(eulons Code:The Contractors Lim.Law
B does not apply to an owner of property who Wilda or Improves thereon,and OCC.GROUP R6.I1NIT5
ew. who doessuchwork himself orthrough Ms awn employees,provided that each
Improvements are not intended oraffered for safe.If,however,thebulldingor TOTAL:
Improvement bsoldwithinoneyearofmarplalan,theowner-builderwlllhave
thtobar4n of proving that he did not build or Improve for Purpose of este.). , QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Lf I,ae owner of the property,am exclusively contracting with licensed
commuters to
construct the pm)ec1(Sm 70K Busmen ns and ProfnaloCode: PERMR LSSVANCE
The Contractor's Livened Law does not apply to an owner of property who ALTER-DRAIN&VPN'[-WATER(EN
or improves thereon,and who contracts for such ptoled.with a FEE SUMMARY
�gRtT+ctor(s)licensed pursuant to the Contncioh License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
. Owner Date RECEIPT M
WORK MAN COMPENSATION DECLARATION �.�S�.�s SCI100L TAX Y_ N_
❑1 hereby affirm f I have o lmurate of consent to aey thea fora RECEIPT a
ce00,Lat<ofWor amperuallan Wuranceara artlRed copythereof(Sec. GAS EA.SYSTEM-1 INCAOUTLEfS PARK FFZi Y N
Policy
a RECEIPT M
aft [IPI CAS FA.SYSTEM-OVERd(FA)
nv / _g! BUILDING DIVISION FEES
W-Kinrtlfied copyb ereby arnlahecL CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRE-ASE7RAP PAID
COMPENSATION INSURANCfiSEW SEWER-SANITARY-STORM EA 200P1'. Date RCCeI t#
Qhis section need not be completed lithe permit b forms hundred dollar
(f100)or tan.) WATER HEATER W/VENT•/E.ECTR ENERGY FEE Y N
I corti(ythat In the perfamearm of thework forwhlch this permit is issued,
I shall not employ any person In any manner so as to became subject to the WATIR SYSlidd/TRGTING
Worken'Comperoalion laws of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQFf: Date RelX:t (#
O NOTICE TO APPLICANT:If,a fter making this Certlflate of Exemption,you
should become subject to the Worken'Compenation proviaans of the Labor TOTAL:
(q Code,you moat forthwith comply with such provisions orthis permit shall be BUILDING �•
LU j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE --
D eofth wo ref trwhicrelsaconstruction isissu kndmg agency for the perform ELECTRIC FEE'
UZ Le- o(thework forwhich this permit bbeued(Sec.3097,Civ.C.) - TOTAL:
O O sanders Name PLUMBING FEE
IL Leader.Addren QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfythatl have read this application and stamthattheabovemformation
R hcornect.l agmen comply with all cilyand county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
>. relating to building conottmctior,and hereby authorlee representatives of this
f. N tlty;.)merupon eabove-memimed property fou Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to ve,IndemNfy an d keep harmless the City of Cupertino Date Recel t#
V
against hablliti ,judgments,roes and expenses which may In anyway accrue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL:
against sad mcoeeeque thegnntin o Ihlapermlt.
z AIR HANDLING IT(OVER 10,000CFM) CONSTRUCTION TAX
Si&ratum otAppllant ontnctor I Dam EXHAUST HOOD(W/DUCT) 'CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATING UNIT(10 100,000 BTU) Date ReceI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTI)) _ TOTAL:
❑Yes MN.
Will the applicant or future building occupant use equiprrent ordevica VENTILATION FAN(SINGLE RESID) PSAAM DATE ,
which emit haaardous air contaminants as deflmd by the Bay Area Air
• Quality Management District? BOILER-COMP OHP OR 100,003 BTU)
4Yea ❑❑Na UC 2 5 1991
h ave read the harardw.rtuleriats requlremenb sender Glupter 6.95 of BORER-COMP(OVER 100,D00 BTU)
the Caluarnla Health&Safety Code,sections 25505,2M3 and 25534. 1 p "IINU
understand that if the building does not corentiy have a tenant,that it B my NEW RESIDENTIAL MECH. SQ.FT �s/ OF IUf�I'1
responsibility to ratify the occupant of the requirements which must be mail Cj11 f V
prior to inuance,of a Certificate of Occupancy. ,►�a y'/F.
Owner or aulhorired agent Data ISSUHD B 1���
TOTAL:
OFFICE COPY