22232 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— .USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bine Ln. Ca e� ins D14 1.Z16 22232
w ra ane:
b iCqM -�*v5t& CITY OF CUPERTINO-BUILDING DIVISION n
c tFa o aN.me: LIc.N.: APPLICATION I PERMIT Cfl
BUILDINC-E,ECTRICALPLUMBING-MECHANICAL CATFOORY CONTROL a
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FE/E/9pr� BUILDING PERMIT;INFO
Addhes PERMITISSUANCE 2s.4!/
ereby LICENSED CONTRACTOR'S DECLARATION
IhthSeWon7Othat lam9=3ofhe under BuslrovWonaol Chapter9dco,imminent. APPLIANCES-RESIDENTIALingwi ]OB DESCRIPTION
lice..hSection force afdeffeen3ofthe Buslnessand ProfessionsC.ode,and my
lirens.Is In full farce and effect. PANES ll
Lirensc Ela® Lick - '
Date Contractor ' UP TO 2DOAMPS
ARCHITECT`S DECLARATION 2m""AMPS
Nmz I undentandmy,Platy shall M used as public records. OVER IDOB AMPS SQ.FT.FLUOR AREA S/SQ.FT.
00
d Licensed Profenloul SIGNSELECTRICAL
6 affirm OWNER-BUILDER DECLARATION SPEC7ALCB2CUfT/MESE N "M p^ L E
Ihereby arm that I am exempt from the Contractor'°Llrevelaw for the P V T
O
following recon.(ge tion 7O31S,Bu°ineu and Profs ..0My dty ar TEMP. ORPOLEINST.
P� cauntywure requltesapermne,coorequiesth Impmve,demsuch,artr
Bit,
a signed
stater to ment that issuance, pursuant
to the ponvalomofpermit e f
file a actors License
La that he t r9(. pursuant to the provisions of the IYIWF.R D VICES �I
3O� Contractor's Llceve Law(Cha)rter9(conurencing with Smilers 7000)of Divi- SWIMMING}POOL ELECTRIC TE
aloo3 of the Businessend Ptofeucou C.M.,that he isexempt therefromaed
F. Sn S the Weis for the alleged exemption. Any violation of Section 7(31.5 by any ��I L
GS' 0U7LETSSWIICHESFI%TUR[S
applicant fora permit subjects the applicant to a civil penalty of not more than 6
ve undred d.11an500)
($ . /
NEW RESIDENTIAL ELECTR
as owner of the property,or my employees with wages as their sole �'�' STORIES TYPE CONSTRUCTION
t < com nation,will d o the work,and the strocaure is not Intended or offered for
$ CI sale(Sec.7014,Buscuas and Professions Code:The Contractors License Law
NE does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UNITS
who doessuch work himself orthrough his own employees,provided that such
Improvemeosamnot intended orolferes for.R.If,however,thebulldingor TOTAL: a
Improvement osold withlnaneyearofcampldiorytheowner-builderwlll have
fl)LturdenofpmWngthat hedid notbuildorimpmveforpurposeofmlc,). QTY, . PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed pg Rl$UANCE /)rl
contractors to construct the project(Sec.7044,Business and Pro& nssebCode: (Y/
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or Improves thereon,and who contracts for such p(oject - -
s with a ,3,�
ryRI}+etor(s)Bcensed pursuant to the Contractor'°License Law. FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE OUTBID
DRAINS FLOG ROOF, SANITARY Y N
Owner Date R AREA,GOND. - RFLF�,N
WORKMAN COMPENSATION DECLARATION FIXNRF_S I'FR TRAP SCI{DOL FAX Y N
❑I hereby orke that I have a lrtcertificate of consent to.py thsure,ora 1 RECEIPT
3800(late.(Worken'Compensatlonlvurance oracertilled copy thereo((5ec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
38 W,lab C.)
Policy p RECEIPT p
Cam any GAS FA.SYSTEM-OVER 4(EA) B UI LDING DTVI SI ON FE CS
[�CedBled copy 6 heed with the cit. GRFASE/INDUMRL WASTE.INTERCEPTOR CHECK FEE
�Cedlfied copy is flied with 1n,sty Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM en 200FT Date Recei t#
(Thlssedien need oat W complMed If the permit isle,ons hundred dollen
(E100)orlyth) -od, WATER HEATER W/VENT/ELECTR ENERGY FEE Y N J
Ill not that In an person In an tmannerhe work so as to become,h this objectmit I,to the 1
I shall not employ any person in any manner at u to become subject to the
Workera'Campensation LawsATERSYSTEM/
ws o(
California.la.Date TREATING - PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ,FE Date Rewi t#
Z O NOTICE TO APPLICANT: after making this Certificate of Exemptlory you
should become sub#ct to the Work ms'Compewtlon pmvbiov of the Labor TOTAL:
p2 Cade,you moat forthwith comply with such provisions or this permit shall be BUILDING r
W ] deemed revoked. '' -
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyaffirm that there is a mmtructlon lending agency for the perform- /y� ELECTRICFEE
M Z an.of the workfor which this Permit 6 Issued(Sec.3097,Civ.C.) lY�
O O lender°Name TOTAL: PLUMBING FEE, t
IL 3— LendceaAdd. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -x
O W I redilythat l have read thisappllcauonand statethatthe above information ,q.
C lemrrect-lagreetoeomplywithalldlyandm ntyo,dhancesand Nalelaws PERMIT (2 FEES PAID:
N reimIng to bullding conswRIon,and hereby authorize representatives of this
f-. Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agror to save,Indemnify an d keep harmless the City of Cupertino Date Reeei t#
agal st lbbWOe°,judgments,mansard expenses which may In anywayaceme AIR HANDLING UNIT(rO 10,ODO CFM) SUBTOTAL:
ag t said 5ity in con sore.!'''th'''e���rating of Ihle perm .
. u„ l ` AIR HANDLING UNCI(OVER 10,OWCFM) CONSTRUCTION TAX
Wigof Appliceontractor DateIX}3AUST HOOD M'/D[K:TICONSTRUCTION TAX PAID:
HARDOUS MATERIALS DISCLOSURE
e appllcantor future building occupant store or handle hazardous HFATINCUNITHO100,000BTU)
maDate Recei t#
terial as dented by the CupeAlno Municipal C W G Chapter 937,and the
Health and Safety Cede Srclon2SS32(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL' W'
n Yea (2 No
Will the applicant or future building occupant use equipment or devices VFNTILATION FAN(SINGLE REBID) t ISSUANCE DATE
4whicheManagement air District? rats as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
4Yes ❑❑No
have J. lealth&rdfut mwt , ri.W255nbundeaChapter5.95 o! BOILER-COMP BTU) _
the GIIlmnla}lealth&Safety Code,Smions 75505,25573 and 25534.I
understand that if the building does not currently have a tenant,that It is my NEWRESIDENTIALMECH. 5Q.FT. ��
responsibility to notify the occupant of the requirements which must be met
prior to Lssuance of a Cedl(irete of Occnpa ocy. /ajh�ycgM�F�^-Y
Owner or authodd reagent Date - ISSUEDB7YY:�a/"VV
TOTAL:
OFFICE COPY