22429APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ect Identification
Building Address;
PERMI'TNO.
17 f'� A /'�
_
2�s�� k U;L7A� i,o.a
224299
mars am one:
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APPLICAlIONSUMILAL A
D •V Sr`' �Sa1^SOS ..
CITY OF CUPERTINO, BUILDING DIVISION,
APPLICATION [PERMIT
SUfLDINGELECnUCALPLUMBINGMECHANICAL
7�
C (J
CATEGORY CONTROL N
Itect/Engines . Lk. No:
QTY - ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
J
Add.?0 .I'Y%Q'✓�
BLOC �ELJ PLUMB MLL11
�`k
1:1 ❑j -1:1LICENSED
PQ2htIT ISSUANCE -
CONTRACTOR'S DECLARATION
Ihereby affirm that l am licensed under provisions of Chapter 9(cSnunenc
APPLIANCES -RESIDENTIAL
• - ]OB DFSCRIFDON
- -
PANELS
lica.se Sccdon7000)of d affeon3ofthe nBuslnessand Pro(essloneCode,and my
license lain full. aeleeR._`/O
LlcenseClass - Lk.N I/tt
t �,-- `G� �s� `L-•
l-+M-�-
Dale y_Contra ctor.vf
ARCHITECI•S DECLARATION
Iundentandmyphwshallbeuwdupub0crerotds. -
'
,Ot-IMOAMIS
OVER1000AMPS -
SQ. FT. FLOOR AREA
VSQ. FT.
SIGNS ELECTRICAL
Licensed Professional
SPECIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License law for the
'
TEMP. METER OR POLE INST.
following re... (Section 70115, Business and Professions Code: Any city.,
countywhlch rcqubesa pem it reconstruct, alter, improve, demollsh,or repair
anystructure pdartoits Issuance, also requlresthe applicant for such permit to
file a signed statement that W Is licensed pursuant to the provisions or the
POWER DEVICES -
-
gWPthING POOL ELECTRIC
Contndoes License Law (Chapter 9(commoencing with Section 7000)of Dial-
don3 ofthe Business and Professions Coda).,that he Is exempt therefrom and
VALUATION
_
the basis for the alleged exemption. Any violation of Section 70315 by any
applicant fora permit subjectathe applicant to a civil penalty of not more than
- OUTLETSSWITCHESFD(TURES
-
five hundred dellare($500). • - •'
❑ I, as owner Of the property, or my employee with wages as their sole
NEW RESIDENTIAL ELECTR SQFr'
STORIES
TYI'ECONSTRl1CTION
romp.nution, wllldothe work, and thestmcture is act Intended or offered for
ssle (Sec. 7044, Business and Professions Code: The Contractor's License law
does nor apply to an owner of property who Wilds or improves thereon, and
whodoessuchworkMmself orrhroagh hisownemployces, provided that such
OCC.GROUP
RIS. UNITS
Improvements arc not Intended ormlered forsale. If, however, thebullding or
- TOTAL,-
OTAL:improvement
improvementissoldwithlnoneyearofemnple umthe owner-Wilderwill have
tl"mmian or proving that he did not build or improve for purpose ofsakd.
LJ L as owner of the property, am exclusively contracting with licensed
contractee to censured the pro44, project (S.e. 70Business and Professions Code:
-
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
/ PERMIT ISSUANCE /n
i
TM Contnttor's License law don not apply to an owner of pmpany who
Wilde or Improve theraon, and who contracts for such Inpjece. with a
gNfactor(a) licensed pursuant to the Coractor'. Ll... Law.
c 1_I 1 am exempt under Sec. ntB & P C for this reasonOUTSI
ALTER -DRAIN & VENT- WATER (EA)
FEE SUMMARY
BALI( FLOW PROTECT. DEVICE
DE FEES
DRAINS FLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEITN P
SCHOOLTAX Y N_
RECEIPT M
Owner Date
WORKMAN COMPMSATIO.N DECLARATION
❑I hereby affirm that 1 have a cartlRcate of consent to self -Insure, or a
MI
certificateofWorkeri Compensation Insurance or a rertifled copy thereof(Sec'
38W LabC) 0/2 — /
PER TRAP
GAS EA. SYSTEM -1 WC.60U'1LE15
-
PARK FEE Y N —
RECEIPT N
Pollry M
Co anp� /!a
GAS EA. SYSTEM -OVER d (FA)
BUILDING DI VISION FEES
Certlfi.d copybhereby furnlslia.
❑Certified copy as filed with the city Inspection division.
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP '
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWER -SANITARY -STORM EA.2WFf. S,Q'Q
COMPENSATION INSURANCE
(rhls section need not W completed If the permit k for one hundred dollars
Date Recti tk
WA'IFR HEATER W/VENT/FlIG.TR
ENERGYFEE Y_ N_
(SIM)orless.)
I mAifythat in the performance ofthe work f.rwhich this permit is issued,
WATER SYSTP.M/TREATING
o u
I shall not employ any person In any manner st. become subject t. the
Workers'Compensation Laws or California. Date
PAID
NEWRISIDENTIALPLMIL SQ.FT.
Applicant
Date. Remi of
NOTICETO APPLICANT: IL after making this Certificate of Exempelon, you
should become subject to the Workers' Compensation provisions ofthe Labor
TOTAL:
-
UILD ING FE
Code, you =at forthwith comply with such provisions orthls permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
TOTAL: •SCO
- /.
'ELECTRIC FEE
I hereby affirm that there is a construction landing agency for the perform
ante ofthe work forwhich this permit is twed(Sec. 3097, Civ. C.)
lander. Name
landar's Adm..,
PLUMBING FEE
.00
QTY. I MECHANICAL PERMIT FEE
MECHANICAL FEE
I certilythm l have read this applicationand state thattheabove Information
0 correct l agree to comply with all city and county ordinances and state laws
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby autharl a representativn m this
city to enter upon the abovcnentlaned property for Impaction purposes.
(We) ae to save, Indemnify an d keep ha,miess the City or Cu panne,
againstl' illtks,' gmenteprta dexpense which may In anywayamruc
ALTER ORADDTO MECH.
'
Date Receipti$
AIR HANDLING OMT (T010,000 CFM)
SUBTOTAL:
agai Id City neon/s`y�)lM1ue ted granting of permit.
AIR HA NDWNG UNIT (OVER 10,000 CFM)
CONSTRUC IONTAX
,III, ture of Applicant/Contractor / Date 7
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum building occupant store or ha nd le hazardous
EXHAUST HOOD(W/DUCT)
CONSTRUCTION TAX PAID: -
HEATING UNIT(TO I OO,ODO BTII)
Date Refer t#
material as deflned by the Cupertino Municipal Cade, Chapter 9.12 and the
I lealth and Safety Coda Stolon 25532(a)?
❑ Yes M No
Will the applicant or future building occupant use equipment ordevices
which emit havardousaircontaminsntsa,deMed bythe Bay Arca Air -
Quality Management District?
c Yee 1� No
have read the hazar aus materials requirements under Chapter 6.95 of
th.Californiaat lith&SafetyCods Sections ZS505,vea tenant, that it
understand that ing not currentlyhavewhich
HEATING UNIT (OVER IW,000 BTU)
TOTAL:7,
00
VENTILATION FAN (SINGLE READ)
ISS ATE
a �7��7yy
r *y�•�
J7
BOILFR-COMP DM' OR 100,0110 BTU)
BOILER -COMP 100,00007L)
N'EW RESIDENTIAL MECF I. SQ.FT
notifhe y
most ba
responsibilitytonotifytheoccupantorthemquircmrma which mwst be met
the occupant he
prior to issuance ora Certificate ofOmpanry.
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ISSUED BY:�
Owner or authoded agent Date
TOTAL:
OFFICE COPY..