22693 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Prom Identification 7 PERMITNO.
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5 VAC P _ 911 CITY OF CUPERTINO-BUILDING DIVISION
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y&ie K-z-- APPLICATION /PERMIT /
. `L/ I-- e.fBUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Eegineer. Lk.No:
milmezr Ar QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
2034 cgatcouF,SE p2{v6� f JOs�
Address: / PERMITISSUANCE tCA
Imo(
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcemed under provisions of Chapter9(comment- APPLIANCES-RESIDENTIAL JOB DESCRIVI'ION
In8wlth5 ion7000)of Dlvision3ofthe BuMi and Pmfe msCode,and my CTL ; I����
license is In fuB d effect ' I /1 v PANGIS - , `_
License Clan_�Lie# 'T TV C ISL —�` —�
Date LQ -1 Contractor T /.yL / �' ��� TPWI
-
ARCHITECPS DECLARATION 201-IOW AMPS
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2 I understand my plans shall be used as public records. OVERI000AMPS SQ.FT.FLOOR $/14.FT.
du Licensed Professional SIGNS ELECTRICAL (1 \' o �Z•Da
Q OWNER-BUILDER DECLARATION l 111
!n` fd SPECIAL CIl2CUIT/MISE
L., , Ihercby a(firm that lam exempt from the Commences License law for the
OZ
I-•y9 following reason.(Section 7031A Business and Professions Code:Any city or Tp�p METERORPOLEINST.
countywhichrequ a apermitmmnstmMalter,Improve,de=lLLh,ormpair
anystmu mpriortolts swame,alsorequimtheappBcantfursuchpemdtto POWER DEVICES
0 U file a signed statement that he e,licane d nt pursuato the provisionsof the
Contractor's Licenve law(Cha 9(comnencin with Stolon 7000)o(Divl- VALUA'I)()N
w G pier B SWIMMING POOL ELECTRIC (J
O sion3olthe Business and Professions Code)orthat he e,exempt therefromand
the base,for the alleged exemption. Any violation of Section 70315 by any I / Q
Q S OITILEISSWTTCHESFlXTURFS v
applicant for a permit aubjetls the applkant to a tivii penalty of oat more than
five hundred dollars(SM. NEWRFSIDENTIALELECTR Q.FT.SNl2UCTION'
❑Las owner of the property,or my employees with wages as their sole
ompcnsatica willdothe work andthesbucture e,not Intended or offered for
5 p sale(Sec 7044,Business and Professions Cade:The Contractors License Law
$ does not apply to an owner a property who Wilds or improves thereon,andR
c,5.. whodoessuchworkh fforthroughhisownemployces,providedthat.ah
Improvements am not Intended proffered forsile.If,however,thebuilding or TOTAL L
Improvement issold withinoneyearofcomplMt Mtheowner-WBdcrwill have
to trim of proving that he did not Wlldorbeproveforpurposcofaalc.). QTY. PLUMBING PERMIT FE'
"1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ISI
me
to construct the project(Sec 70"Business and Prulessions Code:
The Contractor'.License Law rices net apply to an owner of property who
Wilda or Improves thereon, and who contra.for such ptojeM with a ALTER-DRAIN&VENT-WATER(EA)
co,}NB(Taanr(s)Banned pursuant to the Contractors License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec. B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT=
WORKMAN COMPENSATION DECLARATION FI%'fURE&PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have a.rtl0ate of consent to til(-Insure,ora RECEIPT N
artlflrate o(Workers'Compereatlon Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-17NCA OUTLETS PARKFEE Y N-
3800,Lab C.) BBC=#
Policy# GAS EA.SYSTEM.OVER 4(EA) BUILDING DIVISION FEES
Mzyified copy at hereby furnshad. PLANCHECK FEE
❑Certified.pyifikdwlthth dtylvpMiondivbi... GREASE/INDUSIRL WASTE INTERCEPTOR 9 ��'/I / /
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE'IRAP PAID�L
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(X)FT. Date Remi t#
(I'hlssection need not be completed if the permit e,for one hundred dollars
(5100)orloa.) WATER HEATER W/VENT/ELECTR ENE•RGYFEE Y_ N_ St J
I certifythat in the performance of the work for which this permit is asnaed,
1 shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California. Date PAID
O Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making that Certificate of Exemption,you
H N should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you at forthe fth.mply with such provisions or that permit shall be I IN
m
deeed revoked.
III - CONSTRUCTION LENDING AGENCY SEISMIC PEE
CL I herebyaffirmthad there ata constmciion lendiagagency forthe perfomr TOTAL: ELECTRIC FEE
D Zancaofine workforwhichme,permit is mumd(Sec.3097,CIv.C.) PLUMBING FEE
U O Leder.Name
LL F Lender's Address QTY. MECHANICAL PERMIT FEE
U I certitythat l have read this application and statethatthe above information MECHANICAL FEE
O W iscorrect.l agree to comply with all city and county ordinances and state laws PFRMTTISSUANCE l FEES PAID:
C relating tobuilding construction,and hembyauthodae representativesofthls
cit t entero nthe above-mentioned for InspectionALTFRORADDTOMECH. Date Receipt#
I- Z y o po propertyeity of purposes. T
(nst)agrce to jodgmndcmNts an expepess whicharmless h
Clanywa accrue AIRHANDIINGUMT(T010,000CFM) C U
V pertino
against ydgmems,cosh and expense which may In anyway accrue L SUBTOTAL:
a tsaid Cit In consequence ofthe granting ofthispermit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000CFM)
gneture .nt/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
futHAZARDOUS MATERIALS DISCLOSURE
'LRts dp ant the
rcrtino Muccipid Code, hhand9.ha and the HEATING UNIT(TO 100,000811!) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I le.lth and Sa(etyCctfnn=(a)? HEATING UNIT(OVER 100,000 BIL) TOTAL:
❑Yes .
Willthe applicant or fumeebuildingeseepant use equipment ordevices �, VENTILATION FAN(SINGLE RFSID) Q$UA[JCE DATE
which emit haeardovs air contaminants.,defined by the Bay Arca Air 0AXV
Quality ManagementDist ct7 BOILER-COMP QHP OR 1W,000 BTU)
� F1 Yea o t
- I have read the Nazar ousnuterlals requirement under Chapter6.95of BOILER-COMP(OVER 100,000 BTU) (TUT
the California Health&Safety Code,Stolons 25505,25533 and 25534. T PUT
understand a building does not currently have a tenant,that It e,my NEW RESIDENTIAL MECH. SQ.FT
;710
epo ity ton ify the occupant of the requirements which must be mat Co of/asawnr}sr
1oissuance a Certificate of Occupancy.
of��M��
net ora est Dace
TOTL. -— ISSUED BY:_BY:--,/-, Vl
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OFFICE COPY