22268 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Pro'en Identification 7 PERMIT NO.
Building Address: - 22268
nen me, ane:
A
a CITY OF CUPERTINO-BUILDING DIVISION _ p
rat. rsN+me: Lk.No: APPLICATION I PERMIT L
' BNLDINGELECTRICA4I'LUMBINGMMHAMCAL CATEGORY CONTROL»
Arrhltect/Enginesr. Lk No:
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PERMIT ISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
thereby affirm that l am licensed under provisions of Chapter9(commrn APPLIANCESRESIDENTIAL JOB DESCRR'7TON
Ingwith Section7000of Dlvblon3ofthe Buaine..and Pmfmion,Code,and my
license I.In full force and effect. PANELS
Data Class LIeM de `('
Date Cont.ctor
ARCHITECTS DECLARATION 201-1000 AMPS
q f/SQ.FT.
q��uu rs0 O I understand my plans be used u public records. 1
ti�yyy Licensed Professional SIGNSELECTRICAL E R
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M15C
I hereby affirm that l am exempt from the Contractor'.License law for the
qq following reason.(Section 71111 S,Business a nd Professions Code:An cityor C
Kt'Iy ceuntywhich requires a permit tomruhuct,alter,improve,demolbh,orreair TFMI'.MEIFR OR POLE INS(. G
`'0 7 -file
palette,Its bauance,aW requleaslhe applicant for such pererdt to POWER DEVICES
1 5 file a signed statement that he b licensed pursuant to the provisions of the
Ow1� Contractor'sLicense Law(Chapter 9(mmmentlngwlth Section 7000)of Divi- SWIMMING POOL ELECTRIC
UA
BOJ don3ofthe Busln....d Professi.vCode)orthathebeumpttherefromaVALTIqNo
nd
Sn....7777 the basis for the alleged exemption. Any violation of Section 70115 by any
applicant fora permit subject the applicant to a civil penalty of not more than 01177-ETSSWITCHESFIXIT02FS 0 "2 '9
Q five hundred dollars($500).I+ NEW RESIDENTIAL ELECTR
7< �T,asowner t the property,or my employees
or with wages r theirsole �7'T' 6 TYPE CONSTRUCTION
compensation,44,Business
ess and rk and the.0 de:e Is The Contractors intenor offercense L w
or
O sale(-m.P ly 9usbswandf property Code:Theimpov,the.Law
3$ deer not apply torn owner of property who nempoyees,provided
reoR and OCC GROUP RES.UNITS
whodoementsa eartInte dedoroughndowne.If,hoes,providedthatsuch
improvements am notintended earo(co for rale.ILh ser-buflderwilt have
TOTAL:
Improvement band wlthlnorlcycarofc-mpldloMtheowner-bu0derw111 have
tilli proving that he did not build m ireprove for purpose efsale.). QTY. PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with limned FLOOD ZONE APN
rontract-n in roreBuct the project(Sec.7041,Business and Professimu Code: PERMIT ISSUANCE
The Conm tractor's License law does not apply to an owner of property who ALTERDRAIN&VEN7WATER(FA)
Wilds or improvers thereon,and who contracts for such ptojed - -
a with a FEE SUMMARY
ccnador(s)Ilmosed pursuant to the Contractor'.License Law. BACK FLOW PROTECT.DEVICE
Ll]aexempt under Sec. B k P C for this mean.
DRAINS Fli ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION -
pI hereby affirm that I have a certificate of cww.t to self-Insure,ora pp(NggS PER TRAP SC7100L TAX Y_ N_
RECFII »
3800,Lab Cd
nifieste-(Work--'Comw .
peilan lusunceora mnified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Policy If — RECm'T N
CAS FA.SYSTEM-OVER 4(EA)
any BUILDING DIVISION FEES
Certified copy is hereby te
�Certilied copy b filed withh the city
inspection dlvlelon. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANTTARYSTORM FA 200}l• Date Recei t#
(fhb section need not be c-mpleted If the permit b forons hundred dollar P
(Slro)er less.) WATER HEATER W/VEM/ELECTR ENERGY FEE Y N
I cenifythat In the performance of the work forwhich thi.permit b issued,
I shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING PAID
Workers'C.Por..tion Law.of California.Date
rP
A scant
Z O become NOTICE TO APPLICANT.If,after mating this CertBka/e o(Exemptbn,you NEW RESIDENTIAL PLMB. SQtL Date Recei t#
Fshould bee subject to the Works.'Compensation provisions of the Labor TOTAL:
r/1 Code,you must fon hwlth comply with such provisions or this permit shall be BUILDING U
W > deemed revoked.
f] CONSTRUCTION LENDING AGENCY SEISMIC FEE
a
I hereby affirm that there ba construction lending agency for the b Wperform TOTAL: ELECTRIC FEE
7 Z anca of the work for which this permit ued(See.3097,Civ,C.)
V O Lender'sName PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W rma
Irentfythatfhawmadlhbappliationand natethattheabovelnfotion
1 isroreed.I agreetocomplywithaildty.ed couniymelinancetand gate[am PERMUISSUANCE FEES PAID:
} rela0ngtobulldingromtructlon,and herebyaWhedce repre.entativesoflhi.
(— N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save;Indemnify an d keep harmless the City of Cu peruse Date Receipt#
V'
against liabilities,judgments,costa and expenses which may In anyway amue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: 3'
agalrs id City In consequence of 711n,of WapennlL ATR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
g®sure a( leant/ eN.ctMADate EXfiAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSTERIAL ISCLOSURE
Willthe plimntorfutureWildingottvptstoramhandiehavardous HEATINGUMT(TO100,000B7U) Date Recei t#
materials fined by the Cupertino Munlcip Code,Chapter 9.12,and the -
Hralthan fety Cod-Srcion25532(a)? HEATING UNIT(OVER 101,000 BTU) TOTAL:
n❑Yes No 3���
Willthe applicant or Nre building occupant use equipment or devices VEN77LATION FAN(SINGLE RESID) 1$Sl7f1YN�&DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP PEE'OR 100,000 BTU) ���
Vas ❑No d u
havereacithehazardaus material,requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN)
the California Health&Safety Code,Sections 25505,25533 and 25534. [b s ,s48{
understand that if the building doe,not eareently have a tenant,that It my NEW RESIDENTIAL MECH. gQE7 04f: ,CUQono
responsibility to notify the occupant of the requirements which most be met
prior to Issuance of a Certificate of Oceu pa ncy.
t
TOTAL: �
Owner or auihodred agent Data IggOEp gy;
V. I U
OFFICE COPY