22252APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Prr'ea Identification
Boa6,,:
PERMIT NO.
(wTners
22252
ant6e: ' ane:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION I PERMIT
APPLICArURTUMnTA
Cnno-aaora Name:
BUILDING.MF.CTRICALPLUMBINC-MECHAMCAL
CATEGORY CONTROL N
Ite gineer,
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Address:
❑ � ❑ ❑
'PERMITISSUANCE J_ 00
LICENSED CONTRACTOR'S DECLARATION
Ihembyaffirm that l am licensed under pmvislonsof Chapter9(comment
APPLIANCES -RESIDENTIAL
JOB DESCKBTION
PANELS
ingwhh Section 7o00)of Division 3 ofthe Buslnessand ProfcasonsCode, and my
license Is in full fora and effect.
Llano Class Lic.a
^
Date Contractor
` A D� �e�
`/ 1/� /
201-IOOOAMPS
ARCHITECPS DECLARATION
I understand my plans shall be used as public records.
OVER 1000 AMPS
.
SQ. FT. 17^OOR AREA
S/SQ. FT.
SIGNSELECTRICAL
Licensed Professional
-
SPP.CIALCIRCUIT/MISC
OWNER -BUILDER DECLARATION
(tut l am 31.5, B fromthe Contrfessio Llano Law fort he
following reason.(Seaton 7031 S, Business and Professions Code: Any dry or
[wing reason,
countywhlchrequlmaper ttommtrua,alteglmpmve,demolbh,ormpalr
111��� ry Imo'
11 �, II IIn, ! `• B
J V .•
pp
- TEMP. MLTER OR POLE INST. II
any structure prlceio ltsbsuance, abarrequirestheappliant forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contanor's License Law (Chapter 9(commencing with Section 700D) of Divi-
sirn3ofthe Buslnessand Prefesiom Code) orthat he Is exempt therefromand_
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora Nro ut subjects the applicant to a civil penalty of not mouths.
five hundred dollso, MD(l).NEW
❑ I, as owner of the property, or my employes with wages as their sole
compenatlon,wllldothe work andthe structure b not Intended or offered for
POWER DEVICES
I -I •q�•
f Ill
(lie
'
SWIMMING POOL ELECTRIC
OUTLETSSMTCHISFTXTURES
/ / V ON j
TE l6 -
J -4 -4 -
RESIDENTIALEL[CTR SQ'FT.
STORIES
TYPE CONSTRUCTION
mle (Sec. 7044, Business and Professions Code: The Contractors License Law
"
TOTAL:
dos not apply to an owner of property who build, or improves thereon, and
who does such work hireselforthruugh his own employees, provided that such
Improvements are not Intended or offered for sale. If, however, the Wild Ing or
OCCGROUi'
RFS.IINHS.
improvement lssold withnoneyearo(compiniogthe ner-Wilderwlll have
tit,llanden of proving that he did not bund orlmprove for purpmeo(sale.).
Lj L as owner of the property, am exclusively contracting with Ilmnxd
contraders to construct the project (Sec. 7044, Business and Profeselors Code:
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN '
PERMIT ISSUANCE -
no Contactor'. License Law dues not apply to an owner of property who
Wilds or Improvs thereon, dna who contacts for such p.ojects with a
�q—riar(sexem licensed
under Snt to the Comraaor's License Law.
LI I am exempt under Sec. B k P C for this mason
ALTER -DRAIN &VENT- WATER (EA)
FEE SUMMARY '
BACK FLOW PROTECT. DEVICE '
DRAINS FLOOR ROOF, AREA, GOND.
SANITARY- Y N
RECEIPT' N -
Owner Dale
WORKMANCOMPENSATIONDECLARATION'
❑I hereby affirm that I he a mrtifiate of consent mself-Insure, or
certificate of Workers'Compensation Insurance or a certified mpythereof(Sec.
3800, Lab C.)
FIXTURES PER TRAP -
SCHOOL TAX Y N_
RECEBT N .
GAS EA. SYSTEM -1 INC OUI.ETS
PARK Fff Y- N —
'RECEITN
Polity p any
Cam
GAS EA. SYSTEM -OVER 4 (EA)
BUILDING DI VISION FEES
CertlRed copy bhereby famished. .
❑Certlfled copy is filed with the city inspection division.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP-
CERTIFICATE OF EXEMPTION FROM WORKERS'
PAID
SEWERSAMTARYSIORM EA 2WF7
COMPENSATION INSURANCE
(Thisseetion need norbe completed if the permit is forone hundred dollars
(8100)orles.)
I artily that In the performance of the work for which this permit is issued,
Date "Recef tN
WATER HEATER W/NEAP/ELECTR
ENERGYFEE Y_ N_
_
WATERSYSTEA/TREATING
I shall not employ any person in any manner so as to become subject to the
Workers'CompensaHon laws o/Gllfomla. Date
PAID
NEW RESIDENTIAL ELMS, SQ.FT.
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of;you
should become subject to the WorkersCompensation pmwbIte the Labor
'
Date Remi tit
TOTAL:
-
ILDINC EEE
,
Cade, you most forthwith comply with such provisions orthis permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
-
SEISMIC FEE
-
I hereby affirmthat there b a coswctlon lending agency for the perform-
arm of the work for which this permit Is issued (Sec. 3097, Clv. C.)
T<ndcea Name
Lenders Address
I certify thati have aadthisappllatlanand statethat theabove Information
m. I agreetomplywithallchyand counordinancesend state laws
brnamty
TOTAL:
-
ELECTRIC FEE
PLUMBING FEE
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
-
PERMIT ISSUANCE.
FEES PAID:
'
relating to building construction, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purposes.
(We) agrc e, indemnify an d keep harmless the City of Cupertino
against Itka, jad nb, mats ande penes which may in anywayacaue
ALTERORADDTOMECH.'
Date Reccip""
AIR HANDLING (1MT(TO 10,000 CFM)
SUBTOTAL:
U
ago said City In co sequence pit ntin spermit.
/
- AIRHANDENGUMT(OVEK10,000CF)
CONSTRUCTION TAX ,
Arno- to
EXHAUSTHOOD(W/DICT)
CONSTRUCTION TAX PAID:
AZARDOUS MA TER IALS DISCLOSURE
pliant orfbtum building occupant store or handle hazardous
HEATING UNIT (TO IM," BTU)
-
Date ReceI tN
material as defined by the Cupertino Me niclpal Code, Chapter 9.1 7, and the
Iialthand Safety Code s- Section 25532(a)7
❑ Ys In No
Willthe applicant or future building occupant use equipment ordevices
L
HEATWG UNIT (OVER 100,000 BTI!).
TOTAL:
VFNIILATION FAN (SINGLE RESID)
ISSUANCE DATE
which emit haardous air comamham, as defined by the Bay Area Air
Quality Management Dbtrit7 .:
Ys -QNo
4havereadtheb. usmaterlalsmquimm ntsunder CSapter6.95of
BOILER -COMP 0HPOR 100,0M BTM
BOILER -COMP (OVER 10LDW BTU)
the California Health&Safety Code, Seaions25505, 2SS33 and 75534. I
understand that if the Wilding dos not currently have a tenant, that it is my
G^�{
JUN
NEW RESIDENTIAL MECH. SQ.F7.
r ponsibllltytoroti(ythc.pantofthemquirementswhlchmustbemet
'-
priortrlsuanceofaCertifiateof Occupancy.
�I ap1,aF}ry� • 1. sQo t
ISSUEDBY:
Owner or authorized agent Date
TOTAL:
OFFICE COPY