228054
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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification a �Jr �f -
Building Address: /7 // .2
PERMITN/O... //�
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ype a one:
A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
cora ors Name: Lie. No
BUILDINGELECTRICALPLUMBINGMECHAMCAL
CATEGORY
•
CONTROL e
Architect/Engineer. Lk. No: -
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
I
Addren pw T r
El 1:1 .❑
PERMITISSUANCE -
LICENSED CONTRACTOR'S DELLA TION
I hereby af(Irmthat l am Bcensed under provisions of Chapter 9(commem,
Ii no.1 1. fon forceanDlvfect. ftheBueinessandProfeepanaCode,andmy
license Iain full (orae and effect.
APPLIANCESRESIDENTIAL
JOB DESCRII'UON
l�, I..N.sa 0
PANELS
aneeCkn Lont
DLi
Date Contractor
'
201-1000 AMPS
ARCHITECTS DECLARATION
Iunderafand my pi ... full be used as public records.
OVERIITIOAMPS
SQ. Fr. FLOOR
FFLLOOR AREA
S/SQ.FT.
SIGNSELECTRICAL m ? li ^,
Professional
OWNER -BUILDER DECLARATION
I herebyafflrm that I ase exempt fromtheContractor'sLicense Law for the
ALicensed 1
L E ®
f 1
®,�
SPECIALCIRCUIT/MLSC
_
.
TIMPMETER ORPOLE INSL
POWER DEVICES DATE
-
following reason. (Section 7031.5, Business and Professions Code: Any city or
emcrywhlch requinesa permktooretruct, alter, Improve, demolbh,orrepalr
anystructure prior to its lbeemsee,also requirestheappBant forsuch permit to
file a signed statement that he b licensed pursuant to the provisions of the
v r
Conlncto/s License law(Chapter 9(commencing with Section 7000) of Divi -
Mon 3ofthe Business and Professions Code) orthat he b exempt therefrom and
- VALUAIL0
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not mnre than
OVILETSSWITCHESFUCNRES
Ou
Q Q ♦
NEW RESIDENTIAL ELECTR SQ,Fr.
five hundred
owner of the
as owner o(ths property, or rrry employees with wage as their wile
pro
STORIES
TYPE CONSTRUCTION
o pensation, willdothe work and thestroature is nut Intended or offend for
(Sec 7064, an and Code: The roves Llceme Law
o
doesr apply to ow f property or Improves
mp
whodossuchtoanowmr orthrou hhiso nem orlmprovnthercoryand
hisowne.
whodoementsa
OCC.GROUP
RFS, UNITS
nte dedorough
notIntendedIf,ho eprovidedthatsuch
improvementsarenm lotendedoroofc=fferedi asak.If,bo Wildi
TOTAL:
neer-buhe
Improvement bold within oneyesro(complNiory the owner-bullderwlll have
have
th,5*urden of proving that he did not build or improve for purpose of sale.).
as owner of the property, am exclusively contracting with licensed
contncton to oretruct the pec mjen(S7096, Business and Professions Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
"NLJ;
PERMITISSUANCE
The Contractors License Law dm not apply to an owner of property who
Wilds or Improves th., and who contracts for such plojees with a
ra4actor(O licensed pursuant to the Contractor's License Law.
IJ I am exempt under Sec. B & P C for this reason
ALTER -DRAIN & VENT -WATER (FA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY - Y_ N_
RFLEPT Y
Owner Data
WORKMANCOMPENSATIONDECLARATION
QI hereby affirm that 1 ban a certlRate of consent to self-lowre, ora
certificate ofWorkene Cumpereafion Insurance ora certBkd copythereof(Sec.
3800, Tab C3
Porlicy
pD(IVRES PER TRAP
SCHOOL TAX Y N
RECEIPT a
GAS EA. SYSTEM -1 ING4 OUTLETS
'PARK FEE Y_ N_
RECEIPT N
-
Cray - -om
GAS FA. SYSTEM-OVRR4(EA)
BUILDING DI VISION FEES
CCerinedopybherebyfumbhed.
n CertRkd copy b filed with the city Inspection division.
GREASE/WDUSTRL WASTE INTERCEPTOR
PI.ANCHECK FEE
GREASETRAP
CERTIFICATE OF EXEMPT ION FROM WORKERS'
PAID
-
COMPENSATION INSURANCE
(TMs section need not becompleted irthe permit bfa one hundred dollare
SEWER -SANITARY -STORM E.A.200F1'
Date Recd t#
WATER HEATER W/VENT/ELECTR
ENERGY FEE Y N
($100)aless3
I anifythat In the performance of the work for which this permit is lasucd,
WATER SYSTEM/TREATING
I shag not employ any person In any manner an as to become subject to the
Worken'Compensatitm awaof Gllfomk. Date
PAID
Applicant
NEW RESIDENTIAL PLMB. SOFT.
Date Recel t#
NOTICE TO APPLICANT: R, after making this Certificate of Exemption, you
should become subject to the Workers' Compensation provisions of the Labor
TOTAL:
BUILDING FEE
Code, you moat forthwith comply with such pro rialme or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
IherebyafOrmthzttherebacomtmction kMingagenryfmtheperform-
ance of the work for which this permit is issued (Sec. 3097, Clv. C3
Lender'. NamePLUMBING
Lender's Addre.a
I certilythat I have read this appliatkn and state thatthe above information
bortttl. t agree to complywilh all cry and county ordinances and state laws
TOTAL
ELECTRIC FEE
FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
"
relating to bullding construction, and hereby authorize representatives of this
cityto enterupon the above-mentioned property for Impaction purposes.
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
.get. kbNUn,)ud copsanlexpenanwhich mayloanywayamm.
ALTERORADDTOMECH.
Dale Rxeipt#
AIR HANDLING UNIT 10,000 CFM)
SUBTOTAL:
saga dCi con ence of gra rating of this e
AIR HANDLING UNIT (OVER 10,ODOCFM)
CONSTRUCTION TAX
fA can rev r to
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALS DISCLOSURE
HEATING UNIT (TO 100,000BTU)
Date Recei t#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 9.12, and the
I Iealth and Safety Code Section 25532(a)?
❑ Yrs No
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE REED)
ISSUANCE DATE
Will the applicants tore Wilding occupant use equipment or devices
which emit hansious air contaminants as dented by the Bay Area Air
Quality Mawgement District?
Yes ❑ No
have read the hazardous materials requirements under Chapter6.95 of
AH
P
D
q
SEP
BOILER-CAMPOHPOR100,000BTU)
BOILER-COMP(OVER IW OM BTU)
the California Health & Safety Cade, Sections 25505, 25533 and 25534. 1
A
NEW RESIDENTIAL MECH. SQ.FT
and entand that if the Wilding don not orrently have a tenant, that It is my
M
responublliry to notify the occupant of the requirements which must be rrct
prior to Jesus race of a Certificate of Camps ncy.
/s
CIO, Cupertlnt+
ISSUED BY:
Owner or authonmd agent - Date
- TOTAL:
OFFICE COPY