22939 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 7 PEMTNO.
Building Address:
22939
API'LICAIIONSLftIMnT\003 Mo55� ppTlc �UPRRNO L°{I<
nets ams: A one: -
A
gay" IWR 2SS�w6 CITY OF CUPERTINO-BUILDING DIVISION
Cantralm'e NaLi1.N.: APPLICATION / PERMIT
"" GU I"2— BUILDINCELECTRICAI PLUMBINGMECHAMCAL CATEGORY CONTROL If
A"Ited/Engineer. Llc No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addmad55 Z Dp LE 2D• S .a cls• PFRMITISSUANCE ❑ MFCH❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyd(Irm th•tlam Rcensed underprovblone of Chap[er9(mmmene- APPLIANCESRESIDENHAL JOB DFSC ON
Ingwith Sedton7000)of DlvWan3o(the Bush and PmfesdonsCode,and my
limnss b In fu8(ra and effect . PANELS
UP TO 2DO ANTS
- LiconeeC ss Llep tr—
Dale Contract 201I000AMPS
AR CW TION
00 O I understand my plans
shell be used u Public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/`�.FT.
ly Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
Iii aSPECTALCRCUIT/M)SC
Ihercbya(flrni thatlam exemptfcomthe Cont ractor'@Lkenee Law fm the
following reason.(Section 70315,Business and Professions Code:Any city or
7 TEMP.METER OR POLE INST.
aoYstm hkhp q tolatmak¢,also mcLal thea p li entf rsuch,arre air
tto
g any atsuquretatemeitdewaneis dsoregWmthent to
he l fmsialom of to POWERDEVICES
5� � (Ile o signed statement that he b Ilmnsed pursuant to the provblom of the
3 a o Contractor's License Law(Chapter 9(mmmenMg with Section 7000)of Divi- SWIMMING POOL ELECTRIC
.J3 atop3 ofthe Business and Pmfemlora Code)mthat he le exempt them(romand VALUATION
the bash for the alleged exemption. Any violation of Stolon 70315 by any OUTLETSSWITCHESFIXTURFS I
applicant fora permit subjectatheappllcamto a civil penalty of not marelhan 2 Q
$ five hundred dollars(f5W). NEW RESIDENTIAL ELECTR
�n I,act owner of the ro SQ'Fr' STORIES TYPE CONSTRUCTION
❑ p perry,orhe employees therecob
e
compensation,Rowflstra and Pmndthesttude:T e Contractorot intended or License
law
5 O d for
sale(Sec. pply to an owner
df property
Code:The or Impnves Llrenx Law
�$
who dodoAa netxm6
m6 loan owner ofthroug his own
nem orlmproovided thereon,and OCC.GROUP RES UNITS
whodoeaeuchwark Flnaelfmthreugh Nsownemployeea,provided that such
Impmvereents am not Intended oroffemd fmwle.If,hmvever,thebullding m TOTAL:
Improvement beald wlthinoneyearofmmpldtorytheowner-bu0derwill have
t rden of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FE_0DZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
..�..�
contractors to construct the prejM(Sec.7054 Business and Professions Code:
The Contractor',Ltmnss Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
build@ or Improves themon, and who contracts fee such plujects with s FEE SUMMARY
cgp(Tadw(e)limned pursuant to the Contntca.Llmnse law. BACK FLOW PROTECT.DEVICE nal am exempt under See B k P C for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dale RECEIPT R
WORKMAN COMPENSATION DECLARATION FIX.fURFSPER , SCHOOL TAX Y_ N_
❑I hereby dorm that I have a mrttOcate of concent to selfdnare,or a
certificate of Worken'Compervatlon Insurance coacertifkd copythereof(Sec. RECEIPT Y
3800,lab GAS EA.SYSIEM.I INCA OUTLETS PARK FEE Y_ N_
Policy a RECEIPT M
GAS EA.SYSFEN.OVER 4(EA)
om any BUILDING DIVISION PEES
C
[�Certlfled copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CerllBed copy is filed with the city impaction division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2DOFT Date Rami tit
(Thleeectlon need no becmnplcted BtM1e permit iter ane hundred dollars
($100)or less.) WATER HEATER w/VENT/FT.FCTR ENERGY FEE Y N
I mrti(ythat in the performance of thework forwhich this permit is bated,
I shall ploy any Person In an manner n as o m1l to the WATER SYSTEM/TREATING
Works o emotion, w fmnb.Dale PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date Remi t#
Z O NOTICE IC T: Workeafter rO ngt bCtlon preo(Ex,of the
Labor
(- should object to the Workers'Compewtlon provblom o(lhe Labor TOTAL:
W Code,) et(orthwllM1 comply with each proWalomorthlepermltshallbe BUILDINGLA J
W > deemed revoked.
FEE
IL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby of nothat there Is a com/metlnn lending agency for the perform- ELECTRIC FEE
Z arm of the work for which this permit is lamed(Sre.3097,Civ.C.) TOTle
V O Lender.Name PLUMBING FEE
LL U< dees Addreae QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icer*thatlhavereadthbapplicdbnandrtatethattheabovei Tom im
C 6correct.l agree tocomply with all cityand county ordinances end date laws PERMITLSSUANCE FEES PAID:
N raiding to building comtmctlon,and hereby.whodzerepreeentativesafthis
[— Z t toe.terupantheabovcmentionedpmperty(mimpedionpurpoeea. ALTERORADDTOMECH. Date Reeel tit
— e)agree to fy an d keep harmless the City of Cupertino
ago 11 ,j�dgmen andexpenssswhlch may In any ya a AIR HANDLING UNIT(TO]O,f00 CFM) SUBTOTAL:
m Ciy co he granting of thl.R�. !� AIR HANDLING UNIT(OVER 10,0OCFM) CONSTRUCTION TAX
gna /C r )ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM ER LS DISCLOSURI
Wul the applicant or future building occupant stare or handle hazardous HEATING UNIT(TO 100,0W DIM Date ROcel (�
materialasdeflnedbythe C.pertlno M.Md ip.ICode,Chapter9.]Zandthe
Health and Safety Code, HEATING UNIT(OVER 100,000 BT'U) TOTAL:
❑ Yea o
Will the applicant orfunme building occupant use equipment or d evices VENTILATION EAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous su
air cont nt,as deflned by the Bay Area Air
lity Management
Did
QiaBOILER-COMP 0HP OR 100,000 BTU) P /,L
4 Y. No W
B
have read the hazarousmar(ala requirements under Chapter 6.95 of BOILER-COMP(OVER100,D00 BT U)
Califomla Health&Safely Cade,Se i..25S05,75533and2S534.1 NOV -5 1991
on land that ifthebulldingdoasnotcorrenttyhave alenAnLt tit ie my NEW RESIDENTIAL MECH. SQJ-7
nape Ibllltyton n of the requirementewhlchm slbe "
priori Issua o a r.iB pancy.
CITY UI- ' ht' INU
Owner tau agent TOTAL:
Date ISSUED BY:
OFFICE COPY