22231 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identlf callart - - PERMITNO.
Oulidin Add..,:, - 22231
11hou.: q
CITY OF CUPERTINO-BUILDING DIVISION
ctar'.Nra APPLICATION /PERMIT
1,Vd n W2 04 BUILDINC-ELECTRICALPLUMBINC-MECHANICAL CATEGORY CONTROL N
A ct/Fs n Lic.No;
QTY ELECTRIC PERMIT FEE BUILDINGPERMITINFO
-
Address: PERMITISSUANCE.+
LICENSEDCONTRACTOR'SDECLARATION 6W 1:1 Xa: 1:1 • D
Iherobyafflrmlhat lam L'cmaeduMerpr WmsofChapmr9(mmmm MPWANCES�RESIDEM7AL JOB DESC�RRN '
Ingwith Section 7000)0(Dlvielon3ofthe Businemand ProlesslonsCode,and my - ,pBB���LppD�ppp
license Ie In fou f and effect. PANELS
Limn Clam` Lic.
Da - Contractor- UP TO 2M ANTS
/b-vr/\1
ARCHITECT'S DECLARA N , 701-1000 AMPS a�T �F/�
q�q�uu'reO ZO ndenh plansshal as P'.blleremrde. OVER IlX10 AMPS 9 V / \ V /SQ.FT.
6e Fj Te storul SICNS ELECTRICAL
<< OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC M P T E '
o Thereby.flmothat I am exempt(mmthe Contrictor's License Law forthe
5 follawingnhrequ&sage tW Business Profemlonsemle hnydtyor TEMP.MEEK OR POLE INST. > ���/�,
F cauntyng reaon.(Seean7031.omnsi Ass old Professions
Code:Any city
or
.� aeystructure prarto Its 4euarice,oho requirestheappllant forsuch permit to (OWER DEVICES TE
m ,(
r file A signed statement that he is licensed punuant to the provhlons of Me I e �s�
3wI+ Contractor's License Law(Chapter 9(commencing with Section 7000)of Divl- SWIMMING POOL ELECTRIC .L.ai
�0:} eIon3 oflhe Bualneasand ProfemlomCode)ord,u heh exempt lhemfromend VALUATION
0.•,77 the bash for the alleged exemption. Any violation of Section 7R)15 by any O(m,E7SSWITCI IESFl%'1'l1RFS
Applicant for a permit subjects the applicant to a civil penalty of not room than
live hundred dolian(S500).
I,as owner of the pro", NEW RESIDENTIAL ELECTR__SQ.FT, STORIES TYPE CONSTRUCTION
comper❑ p perry,or my employees with wages r thele sole
.[A(Semtion,wBlBothe.d PandthesCde: EA not Intended or offered for
p doe(es nmapfy Busmen and Profmbns Code:The ortropoves Llmwe Law
$$ whoduc such oanowner ofpmpeetywho nem orlmpmvmted on,that and
such
OCC.GROUP RES.UNTI'S
wprovemnt,am khlrnseIntendedor00ghhlaowne.If,ho eprovidedver,the ilding or -- '
Improvement issold ithinomyearofco pl etokth mner-buOderwilI have TOTAL: o�/ '
Improvemontlewid wlthlnomyeam(compietlon,theowner-bu0derwlll have
tI"arden of provingthal he did not build orlmprove for purposeelmle.). QTY. PLUMBING PERMIT FEE
Lj L ae owner of the property;;am exclusively contracting with licensed FLOOD7DNE APN
contractors to construct the project(Sec.70K Business and Profemlons Code: PERMIT ISSUANCE'
The Contnctots License Law does not apply tom owner of property who -
builds or Improves thereon,and who contracts for such pipjem with a ALTER-DRAIN It VENT-WATER EM
cgn{Sactor(s)licensed pursuant to the Contractor's License Law. BAIX FLOW PROTECT.DEVICE FEE SUMMARY
L I am exempt under Sec. B k on
P C for this mas
DRAINS-FLOOR ROOF,AREA,CONTI. - - SANITARY Y N
Owner Data RECER"T 0
.. WORKMAN COMPPNSATIONDECLARATION
❑I hereby affirm that I have a artiflnte of consent to self-Insure,or a PEXTTJRES PER TRAP SCHOOL TAX Y N
rcrllfiate of Worken'Compensation Insurance or a certified copy thereof(Sec. � I RFLEB''TR
3800,Lab C.) CAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y N_ .
CcI1ry N RECEGAS EA:SYSTEM-0VER 4(EA) OING DIV]
f M
Cc GAS.- BUILDING DI VISION Fr.CS
copy h hemby filed
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy h filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.7AOFr, - Date Rcmi iR
Rhlseectlon need not be completed i(the permit hfor ane hundred dollars
(s1I ctrl WATER HEATER w/vENT/ELECTR ENERGYFEE Y N
Iceout emplhat oy
the per(ormanan the workmanner for s tobecis Permit hhmed, -
I shall out employ any person In any manner at m to became subject to the WATER SYSTEM/TREATING '
Workem'Compensatlan laws of California. Dale' PAID
C• Z Applicant
NEW RESIDENTIAL PLM B, SQX. Dale Remi HI
Z Q NOTICE co APPLICANT. .Ree rs'Co this
sationCertificate
prosb Exemption,you
should became eubJect to the Workers'Compensstlan provhlons of the Labor TOTAL:
-CCN Code,you moat forthwith comply with such provisions or this permit shall be - BUILDING
W j deemed revoked. '
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hemby afflrmthat there Is a constmctlon lendlog agenry for the perform ELECTRIC FEE
Z Arco ofthe work for which this permit is]awed(Sec.3097,CIv.C.) TOTAL:
(, 4 larder's Name PLUMBING FEE
LL I— Iandcr'AAddmm QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
1adifythat l have mad thhapplizad0nand statethat theabove Information
O W
R lacorrect.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE. FEES PAID:
} N relating to building construction,and hereby Authorize reprexntalives ofthls -
1•' city to enter upon the abovementluned property for Inspection purposes. ALMORADDTOMECH.
Z
Z (We)agree to cave,Indemnify an d keep harmless the City of Cupertino Dale Rxei IN
A at lIsbiilties,pdgmenh,coanend expenses which my In anywayaccrue AIR HANDLING EMT(TO 10,000 CFM), SUBTOTAL•
a at id Cl consequence of the granting of this permit.
_ f 11 AIR HANDLING UNIT(OVER I0,,0MCFM) CONSTRUCTION TAX
IHhatbic of AppllcaV/Fontradhor -Dam EXHAUST HOOD M/DUCT) CONSTRUCTION TAX PAID:
-HA RDOUS MATERIALS DISCLOSURE
Will theappgaut orfuture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCcei p tq
material as defined by the Cupertino Municipal Cade,Chapter 9.17,and the
I ealth and Safety Code Section 2.5532(a)T ' HEATING UNIT(OVER 100,000 BTU) ' TOTAL: v
❑ Yes rt No
Will the applicant or ture building occupant use equipment or devices" VENTILATION FAN(SINGLE RESID) ISSWANCE DATE
which emit hazardous ate mntaminsnts as defined by the Bay Area Air -
Quality Management District? BOILER-COMP OIa F IB'OR 100,000 BTUII
q YeNa ?
haveread theth&Safet malonatereons 25Sntsundeand 2554.1 of BOB.ER-COMP,(OVPR 10.7,000 BTU) Y
the Califounderstand
t Health A building
Code, at currently
have a tenant,and that I 1 � -
undentandytonotify
ohebuildicupaosnot eroquiro entahickmost
It met NEW RESIDENTIAL MECH. SQ.FI. ti
morto
responsibility c rot i(ytheocte of oftherequlrcrrenle which moat be mel '
prior to issuance of Ccrliflalc of Ocmpanry.
1j� t Q c-
OwnerorAuthorizedagent Date ISSUEDBY:
• TOTAL: '
OFFICE COPY