22832 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
- Building Addreaa:
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weone:
�n�Lwcq..7 CITY OF CUPERTTNOBUILDING DIVISION /O
•• Co orsNa Lie.No: APPLICATION / PERMIT ' [
Arc Itect/Faginee r. Lk.No: BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY COWR(May`O�
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address TISSUANCE ILICENSED CONTRACTOR'S DECLARATION IIERMIe
I hthSyfon7GWatlam Bon3ofthe erpessand mfmionsCodrovudmy APPLIANCFSRESIDENRTAL JOB DESCRIPTION
InI]...I,
G�Lid-�j -tin(Li —k
license la In full(orn end effect. � PANELS..' `v��
License Cla.s LIc.N -
Dale Contractor LIP TO 200AL41!q
ARCHITECTS DECLARATION 701-IODDAMPS
<<
gfl �
z I understand my plardahall be used a a publicrcmrds. OVER1000AMP5 - .FT.FLOOR AREA $/SQ.Fr.
rw� as
fl
d Llcensed Professional SIG NSELFCTRICAL IN
OWNER-BULDER DECLARATION
I-n SPECIAL CIRCUIT/MLSC
7 ti�S IherebyalRmntlatlamexempt from the Contractors License Law forthe
o following reason.l5rction 70315,Business and Professions Code:Any city or
whichTEMP.MEfFR OR POLE INST.
F
county ctume requlrcsa perMttocorobquirmatheapmvgdemol6h,armto 2
any atrucNm priortstatement
t that
he is also thansm!purmano to the for inionsch ofpermit e V
To
file a signed atalemant that he V Bcenxd pursuant to the provisions of the EWER DEVICES
3w Contractors License Law Cha plot 9(commencing with Station 7000)of Divi- SWB.4b0NG POOL ELECTRIC
SOS s1o0mthe Bushes.and Pra(emi .Code)orthathe6e.e pttherefromand VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESFTXTURES
applicant for a permm
it subjects the applicant to a civil penalty of not on than �s..f..+I.
Ithundreddollars($5(ei
NEW RESIDENTIAL ELECTR SQ,FL
7< ❑Las owner of the property,or my employees with wages thele dale STORIES 7lTE CONSTRUCTION
compensation,will do the work and theatrutture V not intended or
oticred far
D sale(Sec.apply
Bu sinessandf property-who
ropeCode:The Contractors Lientue Law
'$ doesnotapplytoanownerafprough hisobuilds memorimproovidadthatand OCC.GROU' RES.UNITS
'EE imodoesents amrkhimse dedonufered owns.If,hoes,p however,
that such
Improvement arenot intandneycarfcomprsala.the oweveyilder illag or have TOTAL;
Improvementtwltl wlthinonoyearofcompletIon,the owner-bulldarwlll have
th-Lifurden of pmving that he did not build or Improve for purpose of dale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor'.License Law does not apply to an owner of property who ALTER-DRAIN ANENT-WATER(EA)
build,or imp.thereon,and who contra(or such p�okct.with a -
ga4actor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lee.f I am exempt under SB k P C for this reason
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
. Date
WORK MRECEIPT NAN COMPENSATION DECLARATION❑ FIXTIRZES PER TRAP 5CI100L TAX Y_ N I hereby affirm that I have a certificate of consent self-insure,or RECEIPT N
3800Q0,Lb
38CJ S FALaof Workers'Camperaatlon Wunnce oracertified copythereo((Sec. GA .SYSTEM-1 INC4OTTLETS PARK FEE Y N
Lab
' Policy X - RFCQPT M
- GAS.F.A.SYSTEM-OVER TA)
Com any BUILDING DIVISION FEES ropy D herebydwith t e city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Codified ropyt(Itd with the city lrtapettlon division.
GREASE TRAP PAID l /yl1��
CERTIFICATEMPE SATIO I NS FROM WORKERS' V ON v
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA"Ff DalC RCCCI t#
(This aettlon need not be completed t(the permit is for om hundred dollars
($]W)orleth) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Iconot thato the person
o/thework(orwhichthispenultc6o the
I shall not employ any person in any manner m u to become subject to the WATERSYSTEM/TREATING
Woplica Companaatlon lawsof CegfornD.Data PAID
O Z NOTIant NEW RESIDENTIAL PLMB._SQI-7. Date Recei !#
Z O NOTICETO APPLICANT:tohe orkers'Com elution povisonsoft eLabu
I" Code, ou mus eurthwit the Worker.'Compewtionpmvbiomo(the Gbor TOTAL:
Uj N Code,you raked.forthwith comply with such provttom ortht permit shall be BUILDING
> deemed musks..
dG CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I henbya!(irm that there Is a construction lending agency for the perform ELECTRIC FEE
Z an olthe work forwhlch this Fermat t Issued(Em.3097,Civ,C.) TOTAL ELECTRIC EEE
00 fenders Name -
LL H Iender'a Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Icertlfythatl have read thtappllcation and state that lheabove Information
O W
1 Iscorrect.I agree to complywith all any and county ordinances and Dutelawa PERMITISSUANCE FEES PAID:
>. relating tobuilding construction,and herebyauthorize representativesofthl.
F Z city to enter upon the above-mentloned property for inspection purposes. ALTER OR ADD TO MECH. -
(We)agree to save,indemnify and keep harMess the City of Cupertino Date Reeel t#
V - 'against llablli0e.,prdgment,cost'and expense.whichmxylnanywayaccrue AIRHANDLINGUMT(TOI0,000CFM)
`agailu old Cityl re pY npa
SUBTOTAL:
Ay
AIR HANDLING UNIT(OVER IQWOCEM) CONSTRUCTIONTAX
I.L age
U m/ ntranorit EXHAUST HOOD(W/DUCT CONSTRUCTION TAX'PAID:
AZARDOUS MATERIALS DISCLOS E
111 cap at or future building occupant atom or handle ha,cardous HEATING UNIT(TO IOD,000 BTU)
cria def by the Municipal Code,Chapter9.17,and the Date Recei t#
i iral1hth an styCodedes—Settlors 75537(x)? HFATWG UMT(OVER IW,IXp BTU) TOT
❑ Yrs LI No
Wllltheapplleant or NO
building occupant use equipment mdevices VENTILATION FAN(SINGLE RESID) ISnSUAn'� ATE
which smut haaardous air contaminants as defined by the Bay Area Air r A
Quality Management District? - B0ILER-CDMP(3HP OR 100,0(10 BTIA
4 Yo he ,No
haveread Health
Safety
Code,Se requlrement5533 and 25534.
of BOILER.COMP(OVQt 100,000BN) 6pR 21 1992
the Calltomt.tifth bSafety Code,Settiona75lyha 5533...75534, I A
understand that ifiithedingdces not a rrcntlyhavea tenant that It tiny NEW RESIDENTIAL METH. SQ.f7. ,
responsibilityce of a Certificate
of ofthenqulremenlewhich must be met
prior to Issuance ofaCertlflcate of Occu an rIaY111V _
P n• CITY Vr l;U
Owner or authorlud agent - Data
TOTAL ISSUED By
OFFICE COPY