22932 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proect Ideml(IaHan PERMITNO.
BulMing Address:lo203 22932
revs one:
Contntto
CITY OF CUPERTIN0.BUILDING DIVISION
LIcNo:
Na . `tel
APPLICATION /PERMIT
BUILDINC-ELECTRICALPLUMBING-MECHAMCAL CATEGORY COpA'Ii WIL
Architect/Fnglneer. LIc.No: V
O s(oio QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..:I Q I /((gyp ( 71DRIA TISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby.fit=that lam licensed under provisions of Gapter9(do c APPLIANCESRIES(DENTIAL 10 FSC......
Ingwlth Seaton 7000).(Diviaiod3ofthe Buslnasand Pro fessloneCode,and my
toff Is In full toand affect. PANELS s
Licence Chea_JSLfe.M ` �\
Dare Contndar UP TO 2DO AMM
ARCHITECTS DECLARATION 201-I000 AMPS
reO�p Iunders/and my pbnssWBW used as publicrecorda. OVER 1000 AMPS L�9R( ' S/SQ.FT.
4,qqF+++ ❑
Licensed Professlowl SIGNS ELECTRICAL
OWNER-BUILDER DECLARATIONLicense SI'FGIALCBICUIT/MISC
7p., Thereby affirm thetlam31.5,Bat..a Cmntrfesee sCode:Gw forthe ���
folbwing reason.6eaion 70115,0 mtma and Professions Code:Any city or
0 i.� TEMP.MEll74ORI'OLE INSf.
� countywhich requbnapenntrocoretma,alter,Improvq demollah,arrepalr
q anystm=mpriortoibiswameaLwrequlmtheappBcantforsuchpermbto POWER DEVICES92-
S file a signed statement that he is licensed pursuant to the provisions of the
eQj O u, Contractors License Law(Chapter 9(commmda with Section 7000)of Divi.8 SWIMMING POOL ELECTRIC ti
SOS slon3of the Business add Profenns ioCode)orthet hehexempttherefromand VALUATION
the Wsisfor the alleged exemplron. Any violation of Seekm 70315 by any MCsCJ
Oaf appflant fora Intent subjects the applicanito a civil penalty of net OUTLE7SSWITCITESFIXNRES cY'morethan O V W
five hundred dollars(55M. NEW RESIDENTIAL ELECTR SQ.FT. SI77RIES TYPE CONSTRUCTION
�n ❑I,as owner of the property,or my employees with wages ae theirsale
compensationMlldotheworkandthestru m isnothetendedor offered for
rah(Sec.7034,Business and Professions Code:The Contractors LIcame Law
$
does net apply to an owner of propeily who builds or impiewn thereon,and OCC.GROUP RFS.UNITS
who doeasuch work himself or through hlsawn empl.yces,provided that such
Improvements are not Intended oroffered forale.f(hmvever,thebulMingor T T
Improvement lasoM within oneyearofcompletion,the owner-buliderw111 have
t arden of proving that he did not Wild or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FOOD ZONE APN
Lj L,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contndors to coretrua the project(Sec.7046,Business and Professions Code: '
The Contractor's License law does rad apply to an owner of property who ALTER-DRAIN kVENT-WATER(EN
Wilde or Improves thereon,and who contracts for such piojecis with a FEE SUMMARY
c�R�faco
come)licensed pursuant to the Contndoe.Lt...Law. BACK FLOW PROTECT.DEVICE
Lf 1 am exempt under Sec B k P C for thin reawn
OUTSI DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Data RECEIPT e
WORK MAN COMPENSATION DECLARATION FLY'RTRES I'FR TRM SCIi00L TAX Y_ N
! �1 hereby affirm that I have a xnl(Wte of coruent to actl4esure,or a RFGE117 K
cep'rt-I�n[e ofWorken'CompevaHonlauranre ora anlfndeopythereot(Sec. GAS E.A.SYSIEM.1 INCA OUILM PARKFEE Y N
3800,Lab CJ
Policy Y RFLEIPF M
GAS EA.SYSTEM-OVER 4(EA)
Cany BUILDING DIVISION FEES
amO Certified copy is herebyfurnished.the city GREASE/LNDUSIRL WASTE INTERCEPTOR PLANCHECK FEG IlGa O�
Certified copy h(Red with the city impaction divlelon.
CERTIFICATE OF WMPFION FROM WORKERS' GRFASETRAP PAID 1
COMPENSATION INSURANCESLWER-SANITARY-STORM FA,2110F1'. Date eeel tN
(Thlssnothm need rad he completed 9 the permit is forom hundred dollars
3100).rless.) WATER HEATER w/vFxr/ELECTR ENERGY FEF.41
I certifythat in the performance of the work for which the.permit Is Issued,
I shall oat employ any paned in any manner so ss to become subject to the WATER SYST M/TREATING
Workers'Compensation Laws of Callfomia.Date P
0 Z Applicant NEWRESIDENTIALPLMB. SQ.FT. [e ReM tN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
Fabould become subject to the Workeri Compensat ion provisions of the Labor OTA :
tl3 Code,you mu at forthwith comply withsucle provhbnsorthis perMtshali be B
W ] deemed revoked.
CONSTRUCTION LENDING AGENCY s—EAMIC FEE
CL TherebyaorkNtlwhkhth peat deanlending agency 7,Civ. .) perform ELECTRIC FEE
L) Z enceof the work for whkhthh pemdthbsued(Sec.3097,C1v.C.) TOTAL:
U O Landers Nacre PLUMBING FL•B
14, F Lender's Add rees QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 W orrect.lhatlhay.plyh ith.Bratmnandstate NattheabovedgInformation t .we
Incorrect.Iagreeto comply with au dtyand muntymrdlnanm and.tate laws PERMIT ISSUANCE �- FEE$PAID:
�. relating to building construction,and hereby authorece representatives of this
F N city to enter upon the above-mentioned property for inspection purposes.. ALTER OR ADD TO MECIL
? Me)agree to save,Indemnify an d keep harmless the City of Cu pestle Date Reeei t14
V
gains abides,judgerents,mpaandexpenees which may in anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
gal MCI Inco enaofthegnrdi.Sof this permit CONSTRUCTIO TAX
" AIR HANDLING UNIT(OVER l0,000CFM)
ignamre of AppUcxru/j40ntmCt0r Dat EXHAUST HOOD M/DUCT) CONSTRUCTIO TAX PAID:
HAZMDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardoua HEATING UNIT(TO 100,000 BTU) Date RCCeI
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Heaith and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,000 BTL))
"SQ Alt
Ely. o
Will theapplicant tore building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which Ernst hazardous air centamensnts as defined by the Bay Area AU
• Quality Management District] BOILER-COMP DHPOR 100,000 RTI))
4hYes aONo
ave read the hacarMa,materials requirement,under Chapter 6.95of BOILER-COMP(OVER 100,000 BV) k I'D
theCalifomia Health k Safety Code,Section 25505,25533 and 25534.I -
understand that if the Wilding does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.FT. NOV'onsiblllty to ndlfy the occupant of the requlmmenta which moat be met I I
priorm us of Ce tteate o(Oc P.my. - VI/ d )A(�
1 1b � ' CIY �r v9
Ownerorauthormda rat - to ISS BY
TOTAL:
OFFICE COPY