22548APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Budding Address: O �il '
PERMIT NO.
22548
nee a one.
- A A
CITYOFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Contractors Name: Lic.Na:
BUILDING-ELECTRICALPLUMBINGMECHANICAL
CATEGORY CONTROL Ng /
('� 6
Archlte a/Engf neer. Lk. No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PERMITISSUANCE
Address:
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc
APPLIANCESRESIDENTIAL
JOB DESCRIPH N
PANELS
ingwlth Section 7000)of Dlvi,ion3ofthe Businemand PmfmslonsCods, and my
license Is In full force and effect.
License Clam Lie.#
/ ,, T'�
(a 2e- Q /
orLice
Date Cmo,
nc�y–
NN r----r� u--- {/L_.l-.(
201-1000 AMPS
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records
OVER1000AMPS
SQ. Fr. FLOOR s/SQ.Ff.
SIGNS ELECTRICAL
Licensed Professional
� OO '
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby afflrrnthat 1 am exempt fromthe Contractors License Law for the
6V1 P lJ T E
TEMP. METER OR POLE INST.
DEVICES DA
following mason.(Sectlon 7031.5, Business and Professions Code: Any city or
county which requires a permit to construct, alter, Improve, demolish, or repair
anyetructure, prior to its bora race, a Lan requires the applicant for such permit to]'OWER
file a signed statement that he b licensed pursuant to the provision, of the
�� J1�rSJ1/g
E
SWIMMING POOL ELECTRIC
OUTLETSSWITCt[ESFIXTURES
Contractor's License Law (Chapter 9(commencing with Section 7") of Divi-
,lonaofthe Business and ProfessionsCode) orthat he Is exempttherefromand
the hisb for the alleged exemption. Any violation of Se <lon 7631.5 by any
appllant fora permit subjects the applicant to a civil penalty of not more than
VAL TION
'
NEW RESIDENTIAL ELECTR SQ.FT.
five rM doBars (SSON.
I__t:
e owner of the property, or my employees with wages as their sok
SID
TYPE CONSTRL'CTIO\'
mpcnsatlon, will do the work, and the structure is rwt Intended or offered for
sale (Snc. 70,14 Business and Professions Code: The Contractors Llcenu Law
docs not apply to an owner of property who Wilds or improve, thereon, and
whodoessuchworkhm selforthrough hisownemployees, provided that such
OCC.GROUP
RES. UNIT'S
- TOTAL:
improvements arc not intended oroffered for sale. l(howevegthe Wildingor
improvement bsold within oneyearofcompletlo, theowner-bullderwlll have
m,Sjurdenotpromng that he dm not Wild orlmprove for Purpose ofsale.).
Lf L as owner of the property, am exclusively contracting with licensed
contractor to ronstrun the project (Sec. 70K Business and Professions Code:
QTY, PLUMBING PERMIT FEE
FLOOD ZONE
ArN
PERMIT ISSUANCE
The Contractor', License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts for such pLopcts with a
,,IlIltjjactoKs)Ilcensed pursuant to Me Contractor's License Law.
u l am exempt under Sec B 6 P C for this masum
ALTER -DRAIN k VENC -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, CONE).
SANITARY RECEIPT M
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby M. that I have •certificate of consent to self -Insure, or
rertificete ofworkeri Compewation Insurance or a certified copythersof(Sec.
3800, lab C.)
FIXNRES PER TRAP
SCHOOL TAX Y_ N_
RECEIVE X
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y N —
X
Policy NRECEIPT
Com any
GAS- F.A. S(EA)
S E
BUILDING DIVISION FE ES
Cedified copy is hereby furol,hed.
❑Certified copy b filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
J ``�
I GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM E.A. 200FT,
COMPENSATION INSURANCE
(This section need not be completed If the permit b for hundreddollars
(s100)ml..)
I certifythat In the performance ofthe work for which this p rent Is blued,
manner so as to become subject to the
I ,nall not employ any person In any man
Workers' Compensation taws of California Date
a COI IN
ENNGJ FE
`
PAID
WATER [iFATER W/VENT/Fl.ECTR
ER
WATER SYSTEM/.]TREATING
NEW RESIDENTIAL ELMS. SQFT.
Applicant
NOTICE TO APPLICANT: ILafter making this Certificate of Exemption, you
should become subject to the Worker' Compensation provisions of the Labor
CCI t# r
A .
BUILDING11-7.00
SEISM '1.00
Cod, you most forthwith comply wRhsuch provbiore, or this permit shall W
deemed revoked.
CONSTRUCTION LENDING AGENCY
TOTAL:
ELECT E
IherebyafHrm thattherebaconxtructlon lending agency perform
ante ofthe work for which this permit b bsued(See. 3097 v. C.)
Lenders Name
Lender'sAddm„
I renifythatl have read thbappllcationaM.tate a0heabove reformation
bcorrecn. l agree to comply with allcityand cozen ordlnanres dstate law,
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID: `f
ALTER ORADDTO MECH.
relating to building constroction, and M1ereby out Drize cop tatives fthis
city to enter upon the above-monuo grope (or Wpect npu ,.
Me) agree to save, Indemnl d keep h rhes, th Ity of penin
agakot liabilities, judgments, nx whit yin an aye a
DBIC RCCCjP
-
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOT –
agaWt ity in conery ofn a tin
9
AIR HANDLING UNIT (OVER 10'" CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX
D:
gru mof App li t/C ntrcior W
AZAR OUSMATER ALSDIS0 RE
Wllltheap cantor rebulldlogoccupant. 1 - rdoos
IN
HEATING UNIT (TO 100,000 BN)
Date Recei
liezl fetyC Section 25532(a)7
m"Wr raan inedbyt Cupertino Municipal Code, Chapter 3 nd the
HEATING UNIT(OVER 100,000 BTU)
TOL:
No
IIt aa pplicantorfu re bnlldmg.pant., Nuipment.,dcvi.
VENTILATION FAN (SINGLE RFSID)
ISSUANCE DA
whicheMhazardousairrimnb as deHrned by the Bay Arca Ab
Quality Management District?
BOILER -COMP QEfP OR 100,000 BTU)
Yea No
have ria teahazar smCode,lsrequircmenbundernd 255 .I of
the
a t and ,that I
understand that it the building dace not currently haveatenanL that ltbmy
understandthatif th b Safety Coes Sections 25505, have
resp.esbllity to notify the occupant 5f the requirements which must be met
P,1A�DI
't
BOILER -COMP (OVI]2100,000BN)
NEW RESIDENT] AL MECH. SQFT.
'onto Lssuanceofa IB<ate of panty.
ot
ISSUED
er or authorlud ag a
TOTAL:
OFFICE COPY