22755 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
building Proem Identification' - PERMIT NO.
• w.e. res . T Ir a4 /arts. - 22755
wnere erre: (/Xone:
G� CITY OF CUPERTINO-BUILDING DIVISION �_I
. Contractor's N..116:' uw.Nw: APPLICATION /PERMIT.
BUILDINGIB-ECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL#
Archited/Engineer. Lie.Nw
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ assn
❑ ❑
LICF.NS ED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under prwklons of Chapter 9(commamc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
IRS with Section 7000)of Division 3 ofthe Business and ProleaslonaGode,and my
license 15
in full form and effect. PANELSI ^�
License Clam Lie• `V]lV '
Dale Contractor
ARCHITECI'S DECLARATION 701-1000 AMPS
90ZO I understand my plans shall be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Licensed I'mfou eRal- SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MMC '
H�j] IherchyafBnn that l am exempt from the Contractor's License law ferthe
z :J following reason.(5ealon 7031.5,Buslneee and Professions Code:Any city or TEMP METER OR POLE INST.
county which Requbna permit to cone uct,alter,Impmem,demolish,or repair
O5aa asystmau ,prlorto lb Issuance,also requireslheapplcent forsuch permit to POWER DEVICES
t�auu O file a signed statement(het he is licensed pursuant to the proNslons of the
Ctractor'.License Law(Chapter 9(commenting with Section 7000),f Divi-
F,3< onWon I of(he Business and Pmfeel,Codet ortbat he leexempt lherefromand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any Wolathm of Section 7031,5.by any OUTLETSSWIT'CHFSFIXTIJRES
❑ -..'scam for.PermBaubject.the applicant to a dvil penalty of not more than
fivejaundred dollars(5.SM. SQJ•7,
$ NEW RESIDENTIAL ELECTS STORIES TYPE CONSIRUCTIDN
IL ass owrer of the property,or he wnkamd he employees with wage as offered
sole
� < is c.tion,will doBusftu iandPdxxsIoestrodurebnm Intended or o(femd(orsypr do
❑ mle(See 7096,Bualneasand Professions Cade:The Gmlerdctoe.license law
doea not apply to an owner of property who builds or improams thereon and OCC.GROUP RFS.UMTS
0. who does.uch work himself orthrough Me own employees,provided that such
Improvements am net Intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement bsold withlnomyearafmmpietlon.lheowner-bullderwill have
thtLtIurden of provingthd he did rust build orlmprove for purpoeotsale.). QTY, PLUMBING PERMIT FEE
U L as owner of the property,am exclusively contracting with Ilrensed FT•OOD 79NE APN
ronttectom to construct the project(Sm 7061,Business and Professions Code: PERMIT ISSUANCE
The Contractor'.License law dm not apply to an owner of property who ALTER-DRAIN AVENT-WATER(EA)
builds or Improve thereon, and who contracts for such pipjects with a FEE SUMMARY
cgRl dor(.)licensed pursuant to the Contractor's Limnse Law. BACK FLOW PROTECT.DEVICE
L�1 am exempt under Sec R k P C for this reason
QUTSIQFHES
DRAINS.FLOOR ROOF,AREA,CONTI. SANITARY Y_ N
Owner Date BBC=N
WORKMAN COMPENSATION DECLARATION FIXTl1RFS PER TRAP SCHOOLTAX Y N
pI hereby.(Timm that I have•certifloste of current to self-Insure,ora RFAEZPPI N
mdifimteofWorkers Compensdimlnsuranmwacedlfied copylharef(Sec.
3800,1ab C.) GAS EA,BYSTEM-11NC.f OUTLETS PARK FFP Y N
Policy# RECEI'T N
GAS PA.SYSTEM�OVER 4(EA)
Com any - BUILDING DIV]SION FEES
Certified copy b herebytume city GREASE/INDUSIRL WASTE INTERCEPTOR PLANCFIEGIC FEE
Certified copy b(Red with the city Inspection division.
CERTIIICATEOFEXEMPTION FROM WORKERS' GREASE TRAP PAID
R RA I
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200Fr. Date Recni t#
(Thboectbn need nm4compliedSUCE ore hundred dellan
(SII armless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]amity emplohat in y
anyhe pew on m an (manner so as to b this pemNt li booed, —
1 mk notemployan/.Lawn f any manneratas 10 become object la the WATER SYSTEM/TREATING
Woken'Compensation lawn of CaBfomla.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SOFf. Date _ Rece1 t#
Z 0 NOTICE TO APPLICANT:ILafter nolorag this Certificate of Exemption,you
F should become subjen to the Workers'Compematlon provbloret of the Labor TOTAL:
fA Code,you must forthwith comply with such provisloru or(his permit shall be BUILDING FEE
111 j deemed revoked.
d E/ CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afflrmthat there is a mnstmains lendingagency for the perform ELECTRIC FEE
Z ante oflhe work for which this permit tat issued(SM 3097,Civ.C.) TOTAL:
V MCC
O Lender.Name— — —ME PLUMBING FEE
H LLndees Addrrs, QTY- MECHANICAL PERMIT
LL U lmdifythatlhavereadthbapplrtlonandoatethattheabmelnfarmatim MECHANICAL FEE
O W Lscorrect.I agree to comply withal)city and couotyordlnances and state laws PERMIT ISSUANCE FEES PAID:
} a relating to building mnstroMon,and hereby authorize representatives of this -
F N dtym enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
2 (We)agree to save,Indemnify an d keep harmlow the City of Cupertino Date ,Receipt#
V agabatllabibiles,Pdgments,"sand expenseowhlch may inanywayamrue AIR HANDLING UNIT(T010,000 CFM)
ag.lrtat Id By in consequma (the Starting of this Permit SUBTOTAL:
AIR HANDLING UNIT(OVER IO,OWCFM) CONSTRUCTION TAX
It A"IPA
wtureof Appll 1/Cntrctw
ZDate EXHAUST HOOD(W/DIK'O CONSTRUCTION TAX PAID:
AZARDOUSM ERIALSDISCLOSURB
WllltheappBont or future building o,mupant store or handle ha,mrdous HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Munldpal Code,Chapter 9.12,and the
1❑Y and Safety Code,Section 75532(a)I - HEATING UNIT(OVER 100,001)BID) TOTAL:
No
Will the applicant or future building ompant use equlpirent or devices VENTILATION FAN(SINCLE RESID) ISSUANCE DATE
whichemithaaardousaU...a ratsasdeflmdbythe Bay Area Alr
1p
silty Management Duarid7 BOILER-CAMP DHPOR 100,000 BTU)
i n
No
Yea A�
have read the harar�ouss materials requirements underChapter 6.95 of ROTI-ER-COMP(OVER 100,000 BTU) r
the California Health A Safety Code,Sect lone 255M,75537 and 75534.1
understand that if the building does not currently havca moan
L that it is my NEW RESIDENTIAL MECE. SQ.FT. SA"•p
responsibility to not lfy the occupant of the requirements which must be mel G( I 9 �r•sas�
prior to Lssua nm of a Certificate of Occupancy.
Owneror authorized agent Data ISSUED BY:
TOTAL:
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