22050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PERMITNO,
Bulldkg Aadnx,:
iii oe 22050
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CITY OF CUPERTINO-BUILDING DIVISION
S��d s� APPLICATION I PERMIT Lt-18-ct
. Contra s4`Name: �jn-� � o:
Archited/Enipmer. 't' Lic.No: BUILDINGELEC7RICA4PLUMBINGMFL}fAMCAl CATEGORY CONTROL.Y tq?(_
—Ahs I� Q'1Y ELECTRIC PERMIT PEE BUILDING PERMIT INFO 7
Addrcec%y�., ,y ,Q,:� De Ci/ PERMITISSUANC.EIZ c(p ut�l
PLUM
LICENSED CONTRACTOR'S DECLARATION �--`
Ihembyaffirmt}at lam licensed under provhlonsof Chapter9(mrmnenc, APPLIANCESRESIDENTIAL - N.� ]Og D6SCR0'TION
ingwlth Scdton7000)ofDividon3.fthe Buslneesand ProfesalonsCode,and my - '^i1JQ 1 /```T
license Is In full form and affect. PANES M"✓`
License Class LieN
Dale Cmdm dor LIP TO 200 A
ARCHITECTS DECLARATION 201-IOW AMPS
^a0O I understand my plainshall be used ss public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 5/SQ./Fr.
Licensed Professional SICNSELECTRICAL' /O [}
6 OWNER-BUILDER DECLARATION - { 2) -1W
I'n SPECIAL CIRCUIT/MLSC e
izr.., 5 Iherebyafflmnihatlamexempt from/he Contractor's l.Icense Law(orthe k�t3p 'ZS an
oo following reason(Stctlon 7031.5,Business and Professions Code:Any city or
county which requlresa pererdtto construd,alter,improve,demolksh,orrepalr P.MEfIR OR POLE INST.
aRystrudum prlorto its issuance also requires the applicant forsuch permit to
POWER DEVICES
O file a signed aatement that he It licensed pursuant to the provisions of the
3µ{� C.ntrador's License Lew(Chapter 9(commendng with 5edion 7000).1 DNvi- SWIMMING POOL ELECTRIC
WW X01 suR3 ofthe Ruanessand Pr.fessimi Code)or(hat he is exempt therefromand VALUATION
x.•57] the basis for the alleged exemption. Any violation of Section 7031.5 by any OU7Lp.ISSWLICHEt}TX.f.U2F5
applicant for a permit subjects the applicant to a civil penalty of net more than Ot�/I' ( LJtJ
H un dreddollars he pr). NEWRMDENTIALELECTR SQ.ET. A[LEE T�'iLCONSTR TION
�n I,ae owner of the property,or my employees with wage as tbek wk NN
aro pensalion,wBldothe work and lhestructure la not Intended or offered for
Osak(Sec.7014,Business and Professions Code:The Contndoes License law
$ don not apply to an owner of property who builds or Improves thereon,and apsass vasks
S
who does such work himself orthreue
gh hlsown employe ,provided that such
Impmvementsarenot intendedor.ffered tarsale.If,however,thebuildingor - TOTAL:
Improvement k sold within oneyear.fcompldion the owner-W llderwlll have
t rden of proving that he did not build or improve for purpose of bale.). QTY, PLUMBING PERMIT FEE COO
1 - 1,as owner of the property,am exclusively contracting with licensedcon -
I PERMITISSUANCE'
The Co tadm.Lito .the Law does
7044,apply t sines and Professions Code: .tom
The Coor Improves
es Cher Law don not apply(ct an owner of property who ALTER-DRAIN&VENT-WATER(EA) '] OD -
Wilds or Improves thereon,and who contracts for such ptvjecte with a FEE SUMMARY
cgRi�ador(eexempt under ane to(heContradofaLlrnnae C fo
BACK FLOW PROTECT.DEVICE
LI I am exempt under Seo B&P C for this reason
1111TR.r1FvFVu
DRAINS FLOOR, EA,ROOF,ARCOND. SANITARY Y N
Owner Data RECEIPT I
WORKMAN COMPENSATION DECLARATION FTX'IURFS PER TRAP SCHOOLTAX Y N
01 hereby affirm that Com have o Ins...e or consent to xy there. ora I 2� RFC=0
3800,Lab Ccertificee.f Worken'C.mpensation Wuanrn oraartifled copy thereof(Sec. GAS-EA.SYSTEM-11NCAOUTLErS �� PARK FEE Y N
Policy N .RECEIPT N
GAS EA.SYSTEM-OVER N(FA)
Cam any BUILDING DIVISION FEES
any
copy is hereby furnished. CRFASEANDUSIRL WASTE INTERCEPTOR PLANICFIE`4FFA I
❑Cert[tied copy b(ikd with the city inspection division. ` '(
CERTIFICATE OF EXEM PFION FROM WOR KERS' GREASE TRAP I' PAID I
I ^�
COMPENSATION INSURANCE SEWER.SANrrARY-STORM EA.200FT. Date - RCCBI 9:L' �(
(Thio section need eat bec.mpl Npermit kforces hundred dollare
(St(p)wlese3 WATER HEATER w/vFNT/ELecTR ENERGY FEE 'Y N
m
I certify that In the perfounce of(he work for which this permit is Issued,
I shall not employ any person N any manner an ae m become subject to the WATER SYSTEM/TREATING
WorkersCompensation Lawsof Callfornia.Date PAID
O Z NOTIAppliCE NEW RESIDENTIAL PPMB._SQ.Fr. Data RC tN
Z O NOTICEcome TO suLICAMheWorkIf,after Workers'
a sation Certificate of Exemption,you
F-
should become mbjectto the Work2re'Compewtlon provisions of Labor TOTAL:
N Code,you must forthwith comply with such provisions orthk permit shall be
. W > deemed revoked. BUILDIN 7177
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE (OO
Ihereby arRrnthat there Is a mrutrocti.n lending agency for the perform ELECTRIC FEE
TOTAL:
,7Z .ander'. work for whkh(hkpermit e Issued(Sec.3097,Civ.CJ t
U O D.enaera Namt - PLUMBING PEE x
I. F Lenders Addrces QTY. MECHANICAL PERMIT FEE
(LL L) Icertlfythatlhavemadthkapplla(ionandstatethat(heabovelnform tion 1 MECHANICAL FEE l
O w Iscorrect.Iagreetocomplywithallcityandcountyodinancesandstatelaws V PERMIT ISSUANCE. V2,00FEES PAID:
O' relating to building mnstroctlon,and hereby authorize representatives ofthis
' N city to enter upon the above-mentioned property for inspection purposes, ALTERORADDTOMECH. (W
? (we)agree I.m Indemnify an d keep harmless the City of Cupertino Date Receipt
V against liabllitie RIM= ex whlchnuyinanywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) i SUBTOTAL:
agal gr 41hisperrut
AIR HANDLING UNIT(OVER IO,000CIM) CONSTRUCTION TAX
Signature of Applin to EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAXP ID:
HAZARDOUS MATERIALS DISCLOSURE
WllltheappBant or future building occupant storemit.:dlehavrdous HEATING UNIT CLD 100,000 BTU)
materlalasdefinM by the Cupertino Municipal Code,Chapter 9.12,and the Date RCcel b
rkalth a Rd Safety Code ion 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Yts No
Will theappllont or tune building ompant use equipment or devices VEMILATION FAN(SINGLE MID) - ISSUANCE DATE r
which emit hazardous,air contaminants ai defined by the gay Arca Air '
Quality Management��satjId7 ' - HOMER-COMPOHPOR100,0p BTU) _ �®
4 Yea 1](I,I s
California
theth&Safet meterlaktions emtntsundeand 25546.95b( BOILER-COMP(OVER lO0,000BN)
-
(he
ersta dt Health&Safety Code, otcurrentlyh veate ant thatIt Y�•
understand(hatn notify
the occupant of
eReg fir hens which
thatIt
mat NEW RESIDENTIAL hfECH. SQ.IT
responsibility to notify the occupant o((he Requirements which mustbe and
prior to Issuance of a Certificate.ofOdvp.my. C*Dfc fl�
Owner or authorized agent Data
TOTAL:
OFFICE COPY' .