22804 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Hullding Project Identification PERMIT NO,
Building Address 22804
7�0 F GGvSSd,44 At
5�Lante. ane: A A
p((L,� GlJES/�CSEG CITY OFCUPERTIN0.6UILDINGDIVISION
Contractor's Name: Lic.No: APPLICATION / PERMIT 37 J
tlUILDING-ELECMCA4ML BINGMECFIANICAL CA'IECORY CONTROL N
Architect/Engineer. Lk.No:
�t! /-lJESflSEaC BUILDING PERMIT INFO
QrY ELECTRICPERMIT FEE
Address:
PERMIT ISSUANCE ❑ O 1:1
LICENSED CONTRACTOR'S DECLARATION
I her by lice.sed ofthe usnesssloosofesacenCrecommenc- APPIJANCESRESIDENTIAL JOB DFSCEUIH'ION
Ingwlth Sect ion force of DivWon3 olthc Buyneasand ProfesslonsC-odq and my a w
license Isinfull forte andc. PAPANELS UP TO 2DO AMPS ,.S
LicenseClass41
.air r6
Date Contractor
ARCHITECTS DECLARATION 201-I003AMP"'
HI0 CO
understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
(0 Licensed Professional SIGNSELECTRICAL
�6 w OWNER-BUILDER DECLARATION
Ihercbyaffirm that lam exempt from the Contractor's License law for the SPECIALCItCNT/M6C
following reason.(Section 7031.5,Business and Professiuns Code:Any city or
rountywhic mqulresaper ttommtmd,alter,impmve,demoibh,orrepair P.MEI'IR OR TOLE INST.
F anystmMmpeortoibL ance,alsorequlrmtheapphontforsuchper tto
file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3 t: Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O yon3a(the Businessand professlonsCode)orthe he is exempttherefroand VALUATION
yd the basis for the alleged exemption. Any violation of Sectiom
7031. 5 by any a �.a
g o¢5Q OUTLETS-SWITCHES-FIXTURESL/ (LJs
applicant mi
cantfora pnrtsubjMsthe applicant toadull penalty of not more than O�
five dred dollars($.500). NEW RESIDENTIAL ELECTR SQFr.
s owner of the property,cur my employm with wages as their sok STORIES TYPE CONSTRUCTION
C7n c pensatlon,Business
Prfraso .Code:Th Contactor License
5 p Ie(Sec.apply
Business and f property Code:The or imp Contractors Lame law
does not apply to rk owner of property who builds or improves thereoq and OCG CROUP RFS.UNITS
whodoesents amrktinten intended
hisownemp,howeprovidedthatsuch
Improvementsarenaintended earofco pl0io.ILh nes-gthebuildingve TOTAL:
Improvement ismid withlnomyearo(completlogtheowner-W iderwill have
t burden of proving that he did not Wildorimproveforpurpearo!sale.). QTY, PLUMBING PERMIT FEE
FLOOD ZONE APN
eI,as owner of the Property,am exclusively contractingwith licensed PERMIT ISSUANCE
contractorscontractorsto construct the project(Sec.7014,Business and
Pro Professlom Code:
The Contractor's License law does not apply to an owner of pmperty wo ALTER-DRAIN&VENT-WATER(EA)
Wilds or improv.thereon,and who metrachi for such p(ojeaia wihth a
,nt(aRor((.)Ikensed pursuant to the Contractor'.License Law. BAIX FIAWPROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. B&P C for this reason
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
• Owner Date RECWPIN
WORKMAN COMPENSATION DECLARATION Sgi00L TAX Y_ N_
F-11 hereby affirm Thal I have a certificate of consent m re �.�S�.�P `�".el(-Insure,or � � RECEI T N
mftIiateofWorken'Comperuatlon Insurance ora certlfed copythereof(Sec. GAS F.A.SYSTEM-11NC.4 OUTLETS PARK FEE Y N
3600,lab C.) RECEIPT N
Policy N
CGAS EA.SYSTEM-OVER 4(EA)
om any - BUILDING DIVISION FEES
Cified copy is hembythMshed. GREASE/INDU n A TO NC ECK FEE
Codified copy islikd with the city inspection division. r � .�
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP
COMPENSATION INSURANCE SEINER-SANIT 'RM FAQ Date Recmi t#
(TAissection need nut be completed tithe permit is foronahundred dollars
($103)or less.) WATER HFATQt W/ FLTA ERC FEE Y N
I certify that in the perfomanceof the work forwhlch this peonit is issued, L�
I shall not employ any person in any manner so as to become abject to the WATER SYAE M/TREATING
Workcrs'Compensation Law.of California. Date PAID
-
0 Z Applicant NEW RESIDENTIALPLMB. SQ.FT. Date Recei t#
Z O NOTICE TO AITLICAM:ILka
akar king this Certificate of Exemption,you
should become subject to the Workers'Comperaation provisions of the Labor TOTAL:
CC
V3 Code,you must forthwith comply with such provisions or this permit shall be BUILDING FEE
W > (-
deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
a I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
DZ once of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
OO Iender'sN.me PLUMBING FEE
LL ~ Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW l certifythat l have read thisappllcatlonand statethauIT heal weinformalan
C Is comed.I.greeto comply with all cityand county Mt I...m,.nd Mata law. PERMISSUANCE FEES PAID:
>_ relating to building construction,and hereby authorise representatives ofthis
I— fA city to enter upon the abovcrmrtlomd property for inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Ind emNfy an d keep harmless the City of Cu pert Ino Date Receipt#
V against llabiBlie,jrdgments,costs a nd expenses which may In any way accrue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL:
.g.Imt..IdC inconsequenceof the a rtugofthI.pcnnut CONSTRUCTIONTAX
AIR HANDLING UNIT(OVER t0,000CFM)
JC CONSTRUCTION TAX PAID:
gnatu o pp ica / ntn o ate FxHAUS'r HOOD(W/DUCT)
H DOUS MATERIALS UISCIASURE
Will theappllcantorfuture building occupantstoreor handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
naterial as defined by the Cupertino Municipal Code,Chapter 9.17,and the -
Health and Safety Cade Section 25533(a)7 HEATING UNIT(OVER t(X,000 BTU) TOTAL:
❑ Yes N No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS ANCE DATE
which emit hares rdous air contaminants as defined by the Bay Area AirNN��
Quality Management District? BOILER-COMP QHP OR 100,000 BTU) Jct./
4Yrs 1-1No
ha ad the h Mous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTIJ) SS
the California Health&Safety Code,Sections 25505,75533 and 25534. 1 1P Il V as
understand that if the building does not currently have a tenant,that it Is my NEW RESI DENIIAL MECH. SQ.FT.
responsibility to notify the occupy nt of the requirements which must be met Nr -
prior to issuance of a Certificate of Occupancy. WyOf C(�a pervne
Owner or authorised agent Date { ' ^
gen TOTAL: ISSUED BY: V 1� `—
OFFICE COPY