22642 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PEILWTNO.
Building Address:
w � I
22642
or, serve e: APPLJCArUR7UWTrAT=A -
CITY OF CUPERTINOLBUILDING DIVISION f�+� •�6�q F
Cono-ators Name: Lic.No: APPLICATION if PERMIT
tl IlSE O BUILDING-ELECTRICAL PLUMBING.MECFLINCAL CATEGORY CONTROL N
Architet/Engineer. Lie.No:
QTY ELECTRIC PERMIT EEE BUILDING PERMIT INFO
Address: PERMITISSUANCE �/ ❑ 2` ❑
LICENSED CONTRunder provisions
RATION t�J �j\
I hereby Nati amlice .ftheBrproviend PrfChapterode,ammc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
In ars,I I.
force of d affeon3 ofthe Buslnessand Pro(essloneCode,and my
Lifers b in full force end dfect. PANELS
Date Contractor —IM TO 200 AMPS
ARCHITECT'S DECLARATION OVER0OAMPS
ODOAM
µOS t 2 I understand my pisco shat W used as public mcoNa OVER 1000 AMT'S SQ.Fr.FLOOR AREA 8/SQ.FT.
E U Licensed Professional ISIGNS ELECTRICAL FINALED IN
<«<¢ OWNERexUILDBR DECLARATION UTE R
C: GZ SPECIAL CIRCUIT/MISC 7
F, Z Ihercby affirm that lam exempHromlhe Contractor's License Law for the -GM P
9F following reason.(Section 7031,5,Businessand Professions Code:Any city or TENS METERORPOLEINST.
countywhich requires permit to construct,alter,improve,demolbh,orrepair „/
yF any structure pdorto its Issuance,also requirestheappllcant for such permit to POWER DEVICES
E d V file a signed statement that he is licensed pursuant to the provisions of the
3u, Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC VALUATION
O don3 ofthe Businessand Profession Code)orthat he b exempt therefromand
g the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil penalty dot morethan OUTLETS-SWITCHES-FIXTURES-SWITCHES-FIXTURES � •��
�[ five hundred dollars(g M. NEW RESIDENTIAL ELECTR SQ.FT.
FILasownarof the property,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,will clothe work andthestructure boot intended or offered for
0 sale(Sec 7044,Busimss and Professlom Code:The Contractor's License Law
NjS docs not apply to an owner of property who Wilde or lmpnevea themn,and OCC.CROUP RIS.AMTS
a who does such work himself orthrough his own employees,provided that such
Improvements am not Intended oroRered forsale.If,however,thebuilding or TOTAL:
Improvement build wlWnoneyearofcompletion,the owner-builderw111 have -
IrytItuNen of proving that he dM not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contactors Llceme law does not apply to an owner of property,who
Wilds or Improves thereon,and who contracts for such pspjecla with a ALTER-DRAIN&VENT-WATER(EA)
actor(s)licensed pursuant to the Contractor's Llmaw Law. FEE SUMMARY
151 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTS I OF FEES
DRAINS.FLOOR RODE,AREA,GOND. SANITARY Y_ N_
,• Owner Data RECEIPT
I WORKMAN COMPENSATION DECLARATION
[3f hFIXTURES PER TRAP A C—/t SCHOOLTAX Y_ N_
ereby affirm that ceself-Insure,I have a rtlRcate of consent to self-Ire,ora l OI/ RKEIPT N
certificate of Wmkers'Compemation lmuraece or a camfied ropy thereof(See. GAS FA.SYSTFM-1 WC.40UTLE15 PARK FEE Y_ N
00,lab C.)
RECEIPT N
1'diry N GAS EA.SYSTEM-OVER 4(EA)
Cc BUILDING DI VISION FEES
ffnm any
CceiOed copy Is hereby furnished. CREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
�nLbd copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Remi t#
(This section need not W completed If the permit is for one hundred dollars
(S1 W)or less) WATER HEATER W/VENT/F2•E-CTR ENERGY FEE Y_ N_
I ceNfy that t the performance of the work for which this permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING
Worker.Compensation Laws of California.Date PAID
Z Z NOTICE TO APPLICANT:It,after making this Certificate of Exemption,you licant NEW RESIDENTIAL PLMB. SQFf. Date Reeel t#
O should become subject to the Workers m
Compeation provisions of the Labor TOTAL:
~ W Codi,you most forthwith comply with such provisions orthls permit shall be BUILDING E •Oo
K j deemed revoked.
W — CONSTRUCHON LENDING AGENCY SEISMIC FEE 1
t1 G I hereby affirenthat there b a mretructlon lending agency for the perform- TOTAL: ELECTRIC FEE
7 Z ance oflheworkforwMchthbpermitbtm (Sec.3097,CIv.C.)
0 0 lancer.Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL EEE
OW l mdifythatl have read thbapplicationand statsthattheabove Information
a bcornat.I<grmtocomplywith allcityand county oNleancesand state laws PERMIT ISSUANCE FEES PAID:
Y relating to building construction,and hereby authorize representativesofthia
I— W chyto cmerupon the above-mentioned property for inspection purposes. ALTRORADDTOMECH.
? (We)agree to save,Indemnify an it keep harmlem the City of Cupertino Date Receipt#
fJ agaimt Lab pdgments,ece. odexpere.which mayln an ayat a AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
agaimt In conscpsence, begantiolici sperm.
AIRHANDLING UWTT(OVER 10,000CF1,I) CONSTRUCTION TAX
Ig of ApPl%es rsct r Doe - EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PND:
HAZARDOUS MATERIALS DISCI.O URE/
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BT) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Cods on25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL:
❑Yes . No
Wlllthe applicant or future be.ilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUALLCE DATE
which emit hara Nom air contarneants as defined by the Bay Area Air
Quality Management Dbtrfct7 BOILER-COMP OFNOA 100,000 BTI) O
moi'
qYs �No BOILER-COh1P(OVER 100,000 BN) �[]A
have read the hazer ommaleriab requirements under Chapter 6.95 of /-111Ka �, Q I�A1
the California Health&Safety Code,Sections 25505,25533 and 75534. I 11 r'7 FF�� iy .
understand that lithe building does not currently have a tenant,that it is my N'EWRESIDENIIALMECH. SQ.IT.
rt to ntify
cedaCe the occupant o(the requirements which rrwst be rrat �
t suancof Occvpmcy.
r•�
�Ow
ner or authorined agent Date ISSUED
TOTAL:
OFFICE COPY