22177 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 122177
a rr
y1/ one: A A A
ialx�,
anteHpr a L!� 8&7 CITY OF CUPERTINO-BUILDING DIVISION � �
cant 77 Lie.No: APPLICATION / PERMIT
ante. BUILDLNGELECTRICAL-PLUMBING-MFCHAMCAL CATEGORY CONTROL N
Archils / cee Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
ULUU
Adders:/Qa70Ups- �� l FERhtITISSUANCE ❑ I ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L�J
Ihereby affirm tbet l am licensed under promons of Chapter 9(commenc APPLIANCESRESIDENTIAL JOB DPSCRIVFION� \`
(egwith Sscion7000)of Dlvblon3 ofthe Busloessand ProfeenonsCocle,and my
license is in fill forceand effect. PANELS
LicenseClass Lk.N
Date ContractorTO 200 AMPS
ARCHITECTS DECLARATION 201-1000AMPS
po+ot I understand my plarashalt be used as publierecords OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
F Licera d Professional SIGNSELFCTRICAL
�6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
t„ J lherebyaffirmthat l am exempt from the Contractor's License Law for the
F� ^ following reeson.(Se Uon 7MLS,Business and Profembns Code:Any city or TEMP.METER ORPOLE INST.
I-' countywhirhrequtresapermittommtmo,alter,bnpmve,dcmoibh,orrepalr
anyatnctureprbrrolb Wuan<e,aLw nqulreatheappBnntfwsuch permit to POWER DEVICES
3' tE7 flk a signed statement that he Ls licensed pursuant to the provisions of the
Contractor's License Law(Clu er9(commencin with Section 7000)of Dist. SWIMMING POOL ELECTRIC
30rn sion 3 of the Busluessand Profesimis Code)orththe is exert therefromand VALDATON
P
a y.' the bash for the alleged exemption. Any violation of Section 70i1S by any OUTLEISSWITCHESFE(TURFS /
appb..t fora pemdtnubjects theapplicant to a civil penalty of not morethan
$ ndreddollan(5500). NEW RESIDENTIAL ELFGRR gQFT FS TYPE CONSRUCI ION'
as owner of the property,or my employees with wages as their sole
7� Ve ponsatton,adtldolheworkandthestmdurelarm Wended or offered for fy�
OIe(&c.7094,Business and Professions Code:The Contractors License law
�5$ does not apply to an owner of property who Wilds or improves thereon,and OCCGROUI' HIS.UNITS deassuch work himself orthecugh his own employees,provided that such
Improvements are not Intended proffered fns sale.If,however,the building or TOTABI
Improvement Issold within one yearofcomplelion,the owner-but llder will have
t�e +rdcn of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODTDNE APN
Io I L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7094 Business and Profembm Cde:
The Contractors License law does not apply to an owner of property,who
Wild.or improves thereon, and who contracts for such pipjects with a ALTER-DRAIN&VENT-WATER BEA)
cgW( exactor(e)li.e. pursuant to the Contractar's License Law. BACKFLOWPROTECT.DEVICE FEE SUMMARY
LII empt un er Ser. B &F for t b reasonOUTSIDE FEES
_ Date DRAINS.FLOOR ROOF,AREA,COND. SANITARY RFCEIFI'N
n WOR C MPE TION DECLAR TIO FIXTURES,PER TRAP SCHOOLTAX Y_ N_
�1 reby affirm that I have a certl0cete,of consent to sel4lnsure,or a RECEBrT N
cemm(1 loot Workeri Compensadom W...d oracertlfadcopythereof(&=. GAS FA. -1 INC OUTLL75 PARK FEE Y N
3800,Lab C.) RECEPT N
Coliry N GAS EA.SYSTEM-OVER 4(FA) BUI LD50 G DI VISION FI!ES
cont any
ffCcetiRed copy b hereby furnished. CREASE/INDUSTRL WASTE INTFRCEIMR PLANCHECK FEE
F-lCedified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-SIURM EA MEI. Date Recti t#
(Thbsection need not be completed if the permit Is(prone hundred dollars
(SIMI.,I..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certify that In the performance of the work for wNch this pemnit la issued,
I shall not employ any person In any manner m as to become subject to the WATER SYS[FM/TRFARING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date ReceI t#
Z O NOUCE TO APPLICANT:If,after making this Certificate of Ran ptwo,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
(A
Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FEE
deemed revoked.
W a CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL I hereby affirm that there b a construction lending agency for the perform ELECTRIC FEE 2Pf,So
D Z ance of the work for which this permit is issued(Sec.3097,Civ.C3 TOTAL:
U O lenders Name PLUMBING FEE
U. F Lender's Addeds QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U l®dlfythatlhavereadthbapplkatbnaMMatethattheaboveinformatlon
O W bcomect.l agree to Comply withaB city and only ordinanmand state laws PERMIT ISSUANCE FEES PAID:
a relating to building construction,and hereby authw4e representatives of this
Zcity to enter upon the above-mentioned property for inspection pu epoem. ALTBRORADDTOMECH. Date RCCCIPt#
(We)agree to uve,Indemnify an d kn keep harrtJethe City of Cu ped Ino O AIR HANDLING I1MT(TO 10,000 CFM)a atliablud
litles,jgments,codsand expenses which may In anyway accrue SUBTOTAL:
gai tsaid City In con uence of the granting of this permit CONSTRUCTION TAX
AIR HANDW NG UNIT(OVER 10,000CIM)
Sig oeof Applcent/Contractor EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Ill thcappbomt or future building occupant store or handle haaanlous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I lealth and Safety Code&ctioo 2S532(a)2 HEATING UNIT(OVER 100,000 BM TOTAL:-- c
E-1Yes No
Will the applicant car future building ompont use equipment ordevices VFNRIIATIONFAN(SINGLERESID) IS4SUANCE DATE
which emit Waardous air contaminants as defined by the Bay Area Air �"
Quality Management District? BOILER-COMP OHP OR 100,IX0 BTI)
Yes ❑❑No
4have read the haaardous materials requirement under Chapter 6.95 of BOILER-COMP(OVER 1!10,000 BTU) u
14AY rC
the California Health&Safety Code,Sections 75505,25533 and 25534. 1 1
understand that if the building does not currently have a tenant,that it is my NEW RFSIDENIRAL MECH. SQ.FT.
resparuibllily,to notify the occupant of the requlrenents which must be met
prior to Issuance of a Certificate of Occupancy. \fie/y}N+ys//..��1Tkj� I�f-Vf-.��0./
Owner or authorised agent Date 1S5UEDBY:�+L/'� rl��\, \CXJ2'(r
TOTAL: :V �J(,J�„J
OFFICE COPY