22059 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro en IdentificationPE MIT NO.
Building O Ii.00 f- h W . 22059
o / .
`rne:te TTY OF CUPERTIN0.8UILDING DIVISION r
fptfAp��1yl{NAam�e:
co k. APPLICATION /PERMIT a '
BLDINC-ELECTRICAL PLUMBING.MFCFM
IA CAL CATEGORY CONTROL 4
Architect/Engineer. Lk.No: UI
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addms I'IXh9TI55UANCE ❑ ❑ ❑
LICENSED CONTRunder SDECns o(Ch ON
I hereby afr7000that l am Hcensedunderprossaind Pro Chapter 9(commem APPLIANCES-RESIDENTIAL - C07L
Ingwllh Sectlon7000)o(deft, n3ofl Buelnessand ProfeselonsCode,and my
license is in(ytr(o—ra_and dreC. �i-7/ 6 PANELS
vis
Llmnec Clra{i 2. Lie.N Lb
Date/�.f Contractor _
ARCHITECTS ECLARATION h11- OOO AMPS
µO!MZZO❑ Iunderstand my plans shall be used as public records. OVER1000AMPS SQ.FT.FLOG FA N/SQ.Fr.
E U Licensed Professional SIGNSELECTRICAL IY N ALED '
«<< c: OWNER-BUILDER DECLARATION SppLIgL CIliCUIT/MIST -FiN
Zp., IherebyafRrrothm l am exempt from the Contractor.License Law for the
qq followingreason.(Section 7031.5,Business and Professions Code:Any elty or
F1pppp":y county which requires.pertNtt...truct,alter,Improve,demolish,or repair TEMP.METER OR POLE INS
qp V❑< anyatrocturepAhrtoReberanee,alsorequirestheappllantfmsuchpermitto LOWER DEVICES
LS V file a signed statement that he is Honied pursuant to the provltlons of the
3w�+ Contracto/s License Law(Chapter 9(commencing with Section 7( GE
SWENMINC 100ECTRIC
SOS sion3ofthe Businessand Professlora Code)orthat he is exempiherefromand
the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWI EXRRtES
applicant for a permit subodathe applicant to a civil penalty of not more than
five hundred dollars($SM.
I,as owner of the roe NEW RFA AL ELECTR SQ.Ff. STORIES TYPECONSIRUCTION
❑ p p k,add
or my employees is or Wended
r thele sole
d for
5�7IQ compensation,wBldolheworKfeado Code:TheC Wended License
Law
F`O sale(Sec.apply to an ow end Prooperty Code: or Impctofa Uttmelad
$ donnossuchtoanownerofprough hisancroorlmprwvidedes eoryand
w$^ whoda¢eeuchworkhimxllorthrough hlsownemployees,providedthat such OCC.GROUIs RES.UNITS
improvements are not Intended orofferead forsale.If,however,thebuilding or TOTAL:
improvement bsald withinoneynrofcompletloNthe owner-bullderwlll have
tlt.Ilurden of proving that he did not build orlmprow for purpose ofsakd. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
11 4 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7011,Business and Profesaloru Code:
The Contractor'.License Lew does net apply to an owner of property who AL77A
Wilds or Improves thereon, and who contracts for such idnjem with a DRAIN&VENT-WATER
c,,33LLI[does)hrnnsed pursuant to the Contractor.License Law. BACK FLOW PROTECT.DEVIC FEE SUMMARY
LJ I am exemp under See B& P C for this nemn
DRAINSFIOOR ROOF, GOND. SANITARY Y N
• Owner Date RECENT p
WORKMAN COMPENSATION DECLARATION MTURES.PERTRAII SCITOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to prythmn,ore RECEn r N
certiflLAb c.Workers'Com1pe/r�wNtxlonlruurana ora artlfAlaed copy themo((Sec. GAS EA.SYSTEM- NCA OUTLLrrS PARK FEE Y N
3800,Iab G., -cV
PoilryY GAS F.A.SY -0VFR4(EA) DING DIVISION
Com any BUILDING DIVISION FEES
[r'Cc dcopy bhercby famished. GREASE/I bTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE PAID
COMPENSATION INSURANCE 5, -SANITARY-BTORM EA 200PI' Date Recei t#
(This section need not be completed lithe permit b lororm hundred dollars
($100)orfyth W ET HEATER W/VENT./ELECTR ENERGYFEE Y N
I certify that o the performance of the work so as to
this permit Is bored,
[.hall not employ any person f any manner at m to berome cubfM to the ATgR SYSTEM/T'REATTNG
Workers Compensation lawn o(OHfomh.Date PAID
O Z Applicant)TLENEW RESIDENTIAL ELMS. SQ.FI'. Date Recel t#
Z O NOTICETO APPLICANT:If,a after maklnm a Ceronlpre o(Faempbn,you
P Code,shoulou=atfbecome rt lovio the ply Mt'Compewiion de.ort previsions p.mthe Labor TOTAL:
it W Code,you muet(orthwlth comply with each provbioru or this permtbe
deemed revoked. BUILDING •
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby.octan that there i a armitconstructionhad lending agency forth.perform ELECTRIC FEE
7 Z area of the work(orwhkh this permltb blued(Sec.3097,Ch,.C.) TOTAL:
(.1 O Lender.Name PLUMBING FEE
LL I— Iender.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Irnrtl(ythatl have read this eppliatlonand statethatthoabove information
4 itmrrect.Iagreetecomplywith all cityand countyordheder.onla=11.we PERMIT ISSUANCE FEES PAID:
N relatingto Wilding corutruction,and hereby authorize representatives ofthb
Z eltyto enterupon the abovo-mentioned property for Inspection purposes. ALTERORADDTOMFOH. Date Recei [#
— to ave,Indemnity an d keep harmless the City of Cupenlnc
inFI Idea,}r V;mvdde,east Iexpen whlchmaylnanywaya¢me AIR HANDLING UNIT 10,000CFM) SUBTOTAL:
gal I i ro s once of the gra ng o(Ihle permit. AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
t umreo(Appgont/C9nlattar Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oceu pant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCeI t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the -
Health and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yon No
Will the applicantor ture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IV of RBtt DATE
which emit harardous air mntamirunts as dellneci by the Bay Area Air 'Caa�
�1J\ .Ilty ManageetDad7 BOILER-COMP HPOR 1 ,000 BTU)
Yes
�r havrcdtheb.❑..mterlab ¢quimmnsunderChapter6.95of 3OI1ER-COMP(OVE1Q00BTU) +g
'V
the Callfornia Health&Safety Code,Sedi.m 75505,25533 and 75534.1
underdapmaandthm Hthebullding don of the requirments which
that It bmy, NEW RESIDENTIAL MfiCH. SQ.Fr naf, r�
prior toiissuty to notify the occupant of the requirements which moat be met \_�'a`\1I
prior to issuance of CertiOate of Ocmpancy.
Owner or authorized agent Data -� � G
SS
TOTAL:
OFFICE COPY