22096 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: PHAQ-j 0111LA 22096
T/?.
n ams: - one:
TUC/ CITY OF CUPERTINO6BUILDING DIVISION
G°^ '"° •"•^� Lm." APPLICATION / PERMIT
sC a R .4) PG M c f �` as19� BUILDING ELECTRICALPLUMBING-MFOHAMCAL CATEGORY CONTROL#
Architect/Engleaer, Lic.No:
Qtt ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address DQLMIT]SSUANCB ❑ ❑ ❑
LIC ENS ED CONTR under SDF.CEI RATION
Thereby affirmthat 0)of Divisim ion
oftheerp Business and
re Chapter
ssions9(coandm ApM.fANCESRFS1DENfUL JOB DFSC ON
in siva l l.f.117000)of d efeon3o(theBusinessandprofessloneCodnand my
License Is In full force and acted. PANELS
License Clam Ic.#
Date Contndor —UP TO 2DOAMM
ARCHITECPS DECLARATION 701-1000 AMPS
as understand my plameluB be used n public records. OVERIOOOAMPS SQ.Ff.FLOOR AREA s/SQ.FT.
O
Licensed Professional SIGNSELFLTRICAL
6 IOWNER-BUILDER DECLARATION n S['ECIALCII4CNT/MISC
Thereby alarm that lem exempt fromthe Committees License Law forihe
following reason.(Section 70315,Business and Profenlane Code:Any dty or
F H� to TEMP.METER OR POLE INST.
mystmdumprlorrequlresapermnce,a emdta th apiLgtfmolbh,or tto
any strodure statement
that he is lice nqu pursuant to the provisions
of dt a POWER DEVICES
O Ole a signed statement that he V licensed pursuant to the provlelans of the
Contractor's License Law(Chapter 9(commencing with Section 7000)ofDivi.
p.,3�1 aIon3 ofthe Business and ProfessionsCode)orthat he h exemp"herefromand SWIMMING POOL ELECTRIC VALUATION
by'� .•]] the basis for the alleged exemption. Any violation of Section 70315 by any
<5 applicant(ora permit subjedsthe applicant to a civil penalty of not mom than OUTLETSSWITCHESFIXrURES
five hundred dollars(s500).
�j.• []I,as owner of the property,or my employees with wage,as their sole "EW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
C�< Ce it wllldo the work and the structure la rent intended or offered for
x O este(Sec.7(K0,Business and Professions Code The Contradoes License Law
dues not apply to an owner of property who Wilds or Improves i hereon and
o•$B^ who does such work himself or through his own employees,provided that such CCC.GROUP RFS UNITS
Improvements are not Intended oroffered forsale.If,however,thebuilding or TOTAL:
Improvement lasold withinoneyearofcomp]Oi°nlheowneobullderwlll have
th *rdenof proving that he did out build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE I7ODDZONE APN
LJ L as owner of the property,am exclusively contracting with Licensed
contractors to construct the project(Sec.7014,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT-WATER(EA)
builds or Improvn thereon -
and who contracts for such p(ojee s with a
dFEE SUMMARY
cgp{porW licensed punuant to the ContradoYa License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec. B k P C for this reeaon
DRAINS FLOOR.ROOF,AREA,COND. SANITARY Y N
. OUTSIDE FEES
Owner Date RECEIPT N
WORKMAN I haveaNSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y_ N_
I hereby affirm that I have a certiaute of consent to eel(-Imre,ora RECEIPT N
cert lcateofWorkeri Coom/peruatlonlruurance or a certified copy thereof(Sec. GAS EA.SYSTEM•11NC.4OUTLETS PARK FEE Y N
Po03•IMb C.I S-0022-1 U—�-92 RECEIPT
h
CAS EA.SYSTEM-OVER4(EAJ
Com env qx e P _ BUILDING DIVISION FEES
Certified copy is hereby�mle
Certified copy la(fled with the city city Inspection division. CRFASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200RT. " Date Rcoei t#
(This sedlon need not be completed i the permit la for one hundred dr
olla
($100).H..) WATER HEATERW/VENT/ELECTR •e ENERGY FEE Y N
I rertifythat In the performanceof the week forwhich this permit is issued, CTry:a
1 shall not employ any person In any manner n as to became subject to the WATER SYSTEM/TREATfNG
Workerc'Compensation laws of California. Date PAID
O Z Applicant NEW RE5 DENT AL PLMB, Date ReCel til
Z O NOTICE TO APPLICANT:ILaRer making this Certificate of Exemption,you
Fshould bemmesubject to the W°rken'C°mpematbn provisions of the Labor TOTAL:
a. N Code,you=at forthwith comply with such provisions or this permit shall be GFE
W > deemed revoked.
CL f] CONSTRUCTION ENDINC AGENCY SEISMIELECTRFEE
IC
Ihercby aork forwhich
leamns[mctlon lending d(Sec. ag7,cy Civ. .)a perform- TOTAL: ELECTRIC FEE
7 Z arm of worktor which this permit is issued(Sec.3097,Civ.C.)
LL O Larded Name PLUMBING FEE
L H Lenderb Addmn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1 certifythat I have read this applicatlonand statethat theabove Information
1 bcorrect.lagreeto complywllh aB dtyand rounty ordinanreeand gatelaws PERMIT ISSUANCE FEES PAID:
} relating to building construction,and benbymthomm repmentatives of thin
F 2 city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. —Date RCCCI t11
_ Mr)agree to save,Indemnify an d keep harmless the City of Cupertino P
against 11 Iltles,Judgment,"a andexpensea which may in any wayacceue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.gains Ity In con era t granting of this permit.
AIR HANDLING UNIT(OVER I B,BDBCFM) CONSTRUCTION TAX
na r o Applicant/Contractor Date EXHAUSTHOODM/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant atom or handle hazardous HEATING UNIT(TO 100,000 BM Date RCCeI tit
material as defined by the Cuperino Municipal Code,Chapter 9.17,and the
Health and Safety Coders�S�ection 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Y. _I No
Will the a ppllcant orfumro building oat pant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hanrdous air mots rdnsnts as cleaned by the Bay Area Air
Quality Management Distrtct7 BOILER-COMP OHP OR 100,000 BTU)
❑Yes n No
(have read the hazardous mammal,requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 75505,75533 and 75534.1
understand that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. �!'
responsibility to notify the occupant of the requirements which=at be met (J
prior to Issuance of a Certificate of Occupancy. 5 den ail
Owner or aulhormist agent Date ISSUED BY:
TOTAL:
OFFICE COPY