22859 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALLPOINT PEN ONLY
'
Building Protect Identification - PERMITNO.
Building Adlmse / >�� p. ./J 17nn n
area: one: ABMIATAL DATE
22 CITY OF CUPERTINO-BUILDING DIVISION. �� (�'
Contracto/e Na ;J ue.N. APPLICATION / PERMIT R
Architect/Engineer. Lie.No: BUILDING-¢ECTRICAL-PLUMBING-MECHANICAL CA I TEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUI ING PERMIT INFO
Address: PERMITISSUANCE' ❑ PLUMB M�hi
� ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that!am licensed under provehanso(Chapter9(comrnene- APPLIANCES-RESIDENTIAL JOBD RI'TION
ingwith Section7000)ofDiviMon3ofthe Businenand Profasion.Code,and my
license sin la ifull force and effect, PANELS
Lmoa
kLie# ILRtl/
Date Contractor UP TO 2DO ANUS
ARCHITECTS DECLARATION201-1000 AMPS
Q�+9 q4 I understand my plats.hall bs used as public record.. -OVER 10DO AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Fi (/ Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPFpIALCIRCUIT/MISC
y � 1herebyaffl.that lam exempt from the Contract ea License Law for the
oo following mum.(Section 7031.5,Business and Professions Code:An city or
Oy` � o ty TEMP.METER ORPOLE INSF.
countywhichmit to construct,
omquialter,Impbantfwolbh, er ttr
any atrudure statement
he MWo sed pursuant
the provisions
of t e TONER DEVICES
rN1 file a signed statement that Iw h licensed pursuant it the provisions of the
3w{-�
CommencesLicenseLaw(Chession(mmmencingorthat els xection mptthe0D)of Divi- SWIMMING POOL ELECTRIC VALU ON
H�Oa eion3oflhe Business and Pro(essbrsCode)orthat hely exempt lherefromand _
•]] the basis for the alleged exemption. Any violation of Section 7a3lZ by any OUTLETSSWITCHESFIXFURES
6pX applicant for a permit subjects theapplkant toe civil penalty of.ot rrorethan
{❑� five hundred dollars($S00). NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property, SQrT ES TYPE CONSTRUCTION
p party,or my employees with wages as their sok
compensation,wOl do the work and the structure is not intended or offered for ,
,J O sale(See 7046,Business and Professions Code:The Contractor's License Law
fj $ does not apply to an owner of property who Wilda or improves thereon,and OCC.GROUP RES.UNITS0.0. who does suchwork himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
improvement iesold within oneyearofcompletim,the owns>W IderwRl have
aflg,(;urden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBINGPERMIT FEE .FLOOD ZONE APN
uu L as owner of the property,am exclusively contracting with Ikenxd PERMIT ISSUANCE
contractors to construct the project(Sec.7044.Business and Professions Code:
The Conemctm.License Law don sect apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
WIkla or improves thereon,and who contracts !riurA ptojecta with a — FEE SUMMARY
rot �1�d pursuant to the -. rector'. 1 ee Law. #"T#1sqW"OM,DEVICE
I am xe t� f Sm /B&P C foj t�a�e
101 1,11- $AREA,COND. SANITARY Y_ N
Own t tl RECI]IPf p
{ OAKMAN O I T)' NCLARATION �' SCHOOLTAX Y N
❑I hereby affi m that I have a certBloate of consent(�o eel!-nwre,Ior a RECE P7 X
certifiateofWm]mVCompeseathm lrsurance ora certifledanp"yihereof(Secs C.40UILECS PARK FEE Y N
3800,Lab C.)
Policy# RECEIPT p
TEM-OVER 4'(16)
Co any i BUILDING DIVISION FEES
5Cerutled copy is hereby fury shed. r CREASE/INDUSIRL WASTEINTERCEPTOR PLANGHEGK FEE
❑CertlRed copy is filed with the city inspection division..
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAY PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 200FT Date Recei t#
(Fhianction need not be completed tithe permit h forone hundred dollars
' ($IW)or len) WATER HEATER W/VENT/¢ECTR - ENERGY FEE Y N
I certifythat N the performance o(the work forwhich this permit is hsued,
I shall not employ any person In any manner An as to become subject to the WATER SYSTEM/TREATING .
Workers'Compensation Laws of Califernh. Date PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z Q NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should became subject to the Workers'Compensation pmask=of the Labor TOTAL:
N
Code,you=at forthwith comply with such provisions orthb permit shall be BU
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
'aILDING FEE' MTV
Z 'Iherebya(firmthat there W a construction lending agency for the perform- TOTAL: ELECTRIC FEE
Z anceoftheworkforwhichthispermi[iaiaeued(Sec.3097,Civ.C.)
U O Lender'sName PLUMBING FEE
LL H Lendcr'a Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertifythatl havereadthisapp0cationand statethatthe above information
C iscorrect.I agreeto comply with all city and county ordinances and Mate lawn PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representatives ofthls
F U) city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date Receipt#
_ (We)agree to save,Indemrafy an d keep harmless the City of Cupertino -
agabstliabillties,Pdgments,mks and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,ODO CFM)
SUBTOTAL:
,against said City in conaequencep(rhe granting of this permit AIR HANDLING UNIT(OVER ID,b00CEM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) COCO S T #PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardow HEATING UNIT(TO 100,000 BTU) Date ecei t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Code Bion 25532W)7 HEATING UNIT(OVER 100,"BTU) TOTAL:
❑Yn No
Wlllth,applicant o ture building ampant useequipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which sent hazardous air contaminants as defined by the Bay Area Air '
al I Management is or - BOILER-COMP OHP OR 100,000]HU)
Yea B�[JosisNo ,
have read the hazargous maledals requirements under Chapter G95 of BOILER-COMP(OVER I W,O(IO BTU) -
IheCaBice.WWWWWWjjj{{$ddTIllealth& Ilk Cmde,Sectiors 5,75533 and 25534.[
undea�an�t itothe buJldingdoca not ry"a haveatenapkhat ithmy NEW RESIDENTIAL MECH. - SQ.Ff
ra miblft onotI eompantofJJ#ere remenlaw th moat be met
p or olssu rtIf, of
�nen or prized agent /Date TOTAL: ISSUED BY:�(' �W-a
OFFICE COPY