22592 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
building A Ito 41t4_0y 47, 22592
n one. APPLIUA I ION SU IM I I I A
CITY OF CUPERTINO-BUILDING DIVISION
• o ranorsNam: —LIc.No: APPLICATION /PERMIT
BUILDING-ELECTRICAUPLUMBING-MECHAMCAL CATEGORY CONTROLN
rchitan/ gine n Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address Iq BLDG UECE PLUMB M�ll
PERMIT ISSUANCE 2� ❑ rye ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I!�
Ibereby affirnthat l arelicrosd under provsions of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of Dlvislon3o(nhe Businessandl#olcssionsCode,and my
Llcvmcense slnfullJorceV LIc.p. as- '11C ' PANELS �c
Llcenx Cb CC U
Date I Contranorz UP TO 200 AbVSV L
ARCHITECT'S DECLARATION 201-1000 AMPS
0]. I understand my plane shall W used as public records. OVER I ODO AMPS IT. A $/SQ.FT.
O
ZLicensed Professional SIGNS ELECTRICAL ]y /7 P p y T P s,.s�
< OWNER-BUILDER DECLARATION w� IVY /�{•a.�a H
rn Fiji SPECIAL CRCIRT/MLSC //
a., 7 owing rason.(Sffiren utlamelLS,Buxempt romme Caeractors Llcenx Law fm the �L 3 � '
K�0O , followingreason.(SMlon7 ttoBu teed and Profealons Code:Any Ary it Z
fpp'� countywhich requlresapermitto mown,alter,lmprove,deralsh,or repair TEMP.METER OR POLE INST. �---_
<4S.a anystmnure prior to its sssance,aLso requiresnheapplicant for such permit to POWER DEVICES /1
EE q GGa7l V file a signed statement that I e Is licensed pursuant to the provisions of the
�3-In II
Contractor's License Law with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
O aion3 ofthe Be
usis and ProfessionsCode)orthat he s eaempitherefeumand /
Q O the bass for the alleged exemption. Any violation or Semon 70315 by any / OIJTLETSSWITCHESFUTURFS ® -V
p,
applicant for.permit subjects the applicant to a civil penalty ofnat more than
y o five hundred dollars(&500. NEW RESIDENTIALELECTRF
F1 1,as owner of the property,or my employees with wages as their axle �' T. STORIES TYPE CONSTRUCTION
C;ZG rompensation,willdotW work andthe anowre s ratWendd or offered for
5 0 sale(Sec.7044,Beatvv and Professions Code:The Contractors Llmve Law
j� does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
whodoessueb work himself orthsough hisown employees,provided thatsuch aR
Improvements are eat Intended offered forsak.If,however,thebullding or TOTAL: -dU
improvement s sold within one yearofcompletlon,the owner-builderw111 have
01etmrden of proving that W did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLDODZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the prejen(Sec.7064,Business and Professions Code:
The Connector's License law does net apply to an owner of property who
Wilds or lmproves thereon, and who contracts for such le aices with a ALTER-DRAIN&VENT-WATER(EA)
}LtPanorp)Bcensd punuan<to the Contracior'sucenx Law. FEE SUMMARY
I__I I am exempt under Sec B& P C for the reason BACK FLOW PROTECT.DEVICE
DRAINS FLOORROOF,AREA,COND. SANITARY Y_ N_
• Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FD(NRES PER TRAP SCIdOOL TAX Y_ N_
❑I hereby arfimn that I have a cemifirate of consent to self-insure,ora RECEIPT N
certificate ofWarken Compeneation Insurance or a certified copythemuf Sec. GAS EA.SYSTEM-11NCAOLILEIS PARK FET. Y N
3800,LabG I —
RECEIPT N
policy N GAS FA.SYSTEM-OVER d(EA) BUILDING DI VISION FE BS
Com any
Certified copy s hereby fumbhed. CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy s filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200F7 Date Reed tN
(Thissection need not M completed if the permit is for one hundred dollars
(f100)or less) WATER BEATER W/VENT/ELFCTR ENERCYFEE Y_ N_
I certifythat in the performance of the week for which this permit Is Issued,
I shall not employ any person In any manner so as to become subject to theWATER SYSTIM/TREA.IINO
Workers'Compensatlonlaws of California. Date PAID
O Z Applicant NEWRESIDENTIALPLMB. SQ.FT. Date Recei IM
Z O NOTICE TO APPLICANT.11,after making this Certlleate of Exemption,you
HW should became object to the Woricers''CamrupeR ion provsions of the Labor TOTAL:
CC Code,you=at fort bwith comply with such provslons or this permit shall M BUILDING FEE
W >_ deemd revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
tlIhembyaffirmthatthem saconstsunlonlendingagencyfortheperform, ELECTRIC FEE -00
M Z ance of the work for which this permit s Issued Sec.3097,Civ.C.) TOTAL:
L) O lender's Name PLUMBING FEE
LL F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1emifythatl have readthsapplicationand statethat theabove Information
C scerrect.I agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Y N relating to Wilding construction,and hereby authorize representatives ofths
� Z city to enter upon the aWeenentlond property for inspection purposes. ALTFRORADDTOMECH.
_ Date Receiptk
V against liabilities,je to udgments,
indemnify andkpenYs whichess myCi�ywayao no
d mens,costs and ex which may In ova attme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
againet Id City In ence m(t granting dthis permit.
Ly�'j ���� / AIR HANDLING UNIT(OVER 10,000GIT1) CONSTRUCTION TAX
S® at"u coofAppllcant/Confinewr 6`� /'�� EXHAUS7HOOD(W/DUCT) CONSTRUCTION TAX PAID:
j1 HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaadous HEATING UMT(TO 100,000 BTU) Date Recei tic
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
health and Safety Cde Sonlon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
m Yes Wo
Will the applicant or future bending occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISPNODATE
which emit hazardoua air contaminants as defined by the Bay Area Air
. Quality Management District? BOILER-COMP OFIP OR 10,000 BTU) ((��!!11/�
4Y. -No BOILER-COMP(OVER 100,000 BTU) fiVG + "
have macithchazar u matedas requirements under Chapter 6.95 of
the Glifomla I Icalth&SafetyCode,Sedione 25505,25533 and 2x536. I �Na�{g1.� sss�
once
NEW RESIDENTIAL MECO. SQ.FT. IXV W {11� 4M
nopovibilitytonnffy eoccupant of the requirements which must be mat 1/Iv YY
prior to' ance rtifirote mupancy.
askOw ur eut orired agent I D to ISSUED g4,;
TOTAL:
OFFICE COPY