22977 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
losbs Ehs-r 22977
�wtutl. ansa: "noA A A
257-3291 CITY OF CUPERTINO-BUILDING DIVISION
°ntract°('SN"" , �Li=�� APPLICATION /PERMIT 1 �
BUR,DING-ELECTRICA41'LAMBING- F HAMCAL CATEGORY CONTROL M
Architect/Fsgineee Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address:
PFRhRTISSUANCE ❑ ❑ E:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that 0)ofamlkm3ofthe er usirslslonsoffe eons ode,an(commume.
my APPPANELS
JOB DE9CF s%ON
Ingwith Section 7000)°!Divielon3oRhegusinessandP fesslonsCode,and my
� . /0 (0282 PwES. Gt1� ll1J£
y
Date Conhasor
shall
be used
�CLARATIO OVER0000AM
AMPS
reO Zp l understand my phm shall be uad s public rends OVER 1000 AMPS SQ.FL.FLOOR AREA 5/SQ.Ff.
9 Q Urensd Profevlaml SIGNS ELECTRICAL
WNER-BUILDER DECLARATION
OSPECIAL CBtCUIT/MLSC
z t.. IhercbyafRnnshat lam exempfromthe Contra sore License Law for the
following reason.(Section 7W 1.5,Business and Profembns Code:Antor
F E'�county which requlresa permit to construct,alter,improve,demolbh,orrepair TEMP.METES OR TOLE INS!.
�a`� .a any structure prior to its Lsssance,atso requireatheapplIcant for such permit to POWER DEVICES
�j file a signed statement that he b ficensed pursuant to the provisions of the
WOw�
Contractor's License Law(Chapter 9(commencingwith Section 7000)ofDivi.
�OS sion3 ofthe Business and ProfessionsCode)orthat he Is exempt therefremand SWIMMING POOL ELECTRIC VALUATI A)C'
Y1 the basis for the alleged exemption. Any violation of Section 7031.5 by any VV
65 slant for permit sub' thea applicant to a civil 1 of not morethan OUTLETS-SWITCHES-FIXTURES
fvP Pe )). Pp penalty O
^GWn7 live 1,as o nerdelof the pr. NEW RESIDENTIAL ELECTR FT,
�n ❑I,compensation,ownerll do theproperty,orhe employeswithwags r thelesole c'Q' STOWFS TYPE CONSTRUCTION
(Sec.70K Business and Prhe work,anssione ruse:TheCom is ntractIntendr'orcensa Law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroffered for sale.If,however,the building or TOTAL:
Improvement issold within oneyearofcomplellon,the owner-builder will have
ths-hu rden of proving that he did net build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEEp(OODyON(g TpNr
4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to mnstroct the prefect(Sec 7044,Business and Prefesiom Code:
The Contrsctors License Law don sat apply to an owner of property who ALTER DRAIN kVENT-WAIFR(FA)
Wilda or Improves thereon,and who contras, for such p�ojem with a
cgp(facmi-W licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B k P C for thin reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RECEIPT N
❑i hereby affirm that I have a certificate of consent to self-Inse rs,or a FDIIVRES'PER TRAP SCHOOL TAX Y N
cenifiateof Workers Compemationlm nncemacenifkdmpythercuf(Sec. - RECEIPTM
380D,Lab C.�..s 11 Q 7� GAS EA.SYSTEM-1 INC.4 OUTLETS PARKFEE Y N
Pollry N_I_Z 212 5 Y -I (J RECER'r p
Co�any !� CAS FA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
Certified copy l{h in sh GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�Certltled copy b(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE
(Thissection need not becomplamil ifthe permit lefmom hundred dollars SEWER-SANITARY-STORM EA.20OFT. Date Recti t#
($1 I0)orfWATER HEATER W/VENT/ELECTR ENERCYFEE Y N
Irtify that
mIssued,th
reat in the performance o(thewk(or which this permit is
I shall not employ any person m any manner n n to become arbject to tet
O Worlken'Compensaaon Uwe ofCaRfomia.Date-
Z
SYSTGI/TREATING PAID
Z 0 NOnCETOAPPLICAM.1f,aNermekingthb Cenificateof Exemplon,you NEW RESIDENTIAL ELM& SQFr, Date Recei t#
should become subye to the Workers Compensation provisions of the Labor
N Code,you must(orthwith comply with such pnevisioruorthb permitshall be TOTAL:
W > dem �
deemed revoked, BUIL INCA ^
Ix p CONSTRUCTIONLENDINGAGENCY c SEISMIC FEE
7
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
O once ofthe work for which this permit b Lsseed(See.3097,Civ,C.) TOTAL:
U _ Unders Name PLUMBING FEE
ly 0 dersnQ Y. MECHANICAL PERMIT FEE
O W Iceni(ythatl hathatl ve rcatlthb appBcatbnand smtethat theabove ln(omuBm MECHANICAL FEE
EL bcorrect.Iagreelo complywithallstyand muntyordlnanccsand state las» PERMITIS5UANCE PEES PAID:
} W relating to building comtmctim,and herebyauthoAurcpresentativesofthis
Z city to enter upon the above-mentioned property for Wpefien purpose, ALTERORADDTOMECH.
Me)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
agabmtllabllitlea,pdgmenb,mnsandexpen whichmayinanywaya.a AIR HANDLING UNIT(To 10,000 CFM) SUBTOTAL:
against d in sequence of the Ms it.
al AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTIONTAX
5 mtu °(Applicant/Imumsm Data EXHAUS'rHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.1$and the Date ReceI t#
I lealth and Safety Code Section 255320)2 HEATING UNIT(OVER 100,000 BTU)
No IOTA
❑ Yea I]No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air ,
. Quality Management District? BOILER-COMP OHP OR 10,0(0 BTU)
Yes F"l No
have read the h azar7iousmaterlals requirements a"der Cha per 6.95 of BOILER-COMP(OVE210,(100 BM /ta
the GllfernialfeRhkSafetyCode,Sesions25505,25533and2S534. I P }]
understand that ifthe buildsngdoesnotmrrentlyhaveatenant,that it b my NEW RESIDFN77AL MECH. �.FT
rnpomibllity to nclify the camps.of the mgWrements which at be met
�rssuan-ce e �nty. # 011
]�
I I-I 3-q 1 cis d 191
Owner or authorized agent Date •/
TOTAL: ISSUEDBY:_
OFFICE COPY