22643 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN-ONLY
Building Project Identification _ PF]LMIT NO.
Building Address:
ow W ova c ZZ643
r. ante: one:
wne CITY OF CUPERTINO,BUILDING DIVISION - .� /` .N
Cgntrpaor'c Name: Li No: APPLICATION,/ PERMIT 'I,�)
�• A hltetl En neer. Lte a' BUILDINGELFCTRICALPLUMBING-M ECIBAMCAL CATEGORY CO
b b
ELECTRICPERMIT ' •'FCE
,BUILDING PERMIT INFO
BLDG �LLI ' PLUMB NIELH
F.NSIiD . PEIMTISSUANCE ,(X J ❑' ❑ ❑•
LICNTRACTO D: IA ATION -
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCESRESIDENIIAL - JOB DESCRIPTION
Ingwlth Setl1an7000)of Dlvbion3o(the Butlnessand ProfaalonaCode,and my
license le In full fo..nd effect. PANELS -
LlcenseCU. Lie# -
Date Con<ranor '
ARCHITECTS DECLARATION- 701-1000 AMPS �s
00 P OVER 1000 AMPS _ y/���AN 5/SQ.Ff.
z 1 understand my plan shag W used m publicrecords. N
SIGNSELECTRICAL 4
Licensed Professional e '
< OWNER-BUILDER DECLARATION SP
FCIALCIRCUIT/MISC v �,�
p„ Thereby affirm thatI am exempt the Contractor's License Law for the
02. following reason.(Section 70315,Business and Professions Code:Any city or TEMP METER OR POLE INST.
P I"' countywM pd.,lto it. maul corutruct,altereappligdemo0sh, er stir 2� �9
q 5 1 .wctnd namrtolts that he U iturse pursuant t the provisions
of tto POWER DEVICES C••
k` S Rle..gned statement that he is r 9(co d pursuant it the Eon 7") of the V
Q60u,ff..
Contractors of the License.ndLaw(Chapter9(mmmendngwithomptherefof Divi- SWIMMING POOL ELECTRIC - VALUATIO�NxY� �•eA. �
thesiobasis for
the alleged
Any
rlation that f exempt therefrom and � �— OW—W
Sot......777777 the Wala for the alleged exemption. Any t to violation of Benton no m by any '.�,,,11)
p+
applicant fora permit subjects the applicant too civil pemltydnot morethan OUTLETS-SWITCHES I
five hundred dollars($500). SQ.FP. STORIES TYPE CONSTRUCTION
NEW RESIDENTIAL ELECTR
4) �n ❑I,as owner o(the properly,ormy employees with wage as their sole
compensatlon,w0lda the work and the structure is not Intended or offered for
sale(Sea 7014,Bu.inem end Professiom Code:The Contractors Llmme Law -
�r $ does not apply to an owner ofproperty who Wilds or Improves thereon,and ,
FS^ whodocasuchworlehlmselforthrough hisown employees,provided thatsrch OCC.CROUTE RES.UNTI'S
Improvements are not Intended oroffered forsale.If,however,thebuildlog or TOTAL: "
improvement Lsaold within omyea rof completion,the owner-builderwlll have
thc�urden of proving that he did rm Wild or improve for purpose of sale.). CITY. ".' �1PLUMBIN&PERMIT.,: FEE„r p(-Opp 7pNE APN
u L as owner of the property,am exclusively contracting with limned
contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractors Lireme Law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wads or improves thereon,and who contracts for such pka*ca,with a
ogla(actor(s)Bcensed'puauant to the Contractor's Lkenw Law, BACK FLOW PROTECT.DEVICE. FEE SUMMARY ) ,
Lf I am exempt under Sec.. B k P C for this reason
Owner 4 Date S
DRAINFLOOR ROOF,AREA;COND. SANITARY .Y N '
RECEIPT'p
WORK MAN COMPENSATION DECLARATION ppmJRES,PER TRAP SCHOOL TAX Y N
❑P hereby affirm that I have o rlrtiante or convent to spythmre,ora RECEIPT'N
3800,ce�ifiabofWorken'Compensatianlmurance ora mrtlflM ropythemof(Sec. GAS EA.SY9TEM-1 INC.4OUTLEIS PARKFEE Y N
3800,his CJ ,
Policy R GAG EA.SYSTEM-OVER - RP-CEBxTN
Com y BUILDING DIVISION FEES
ined copy l4 filedwith
the city
GREASE/PNDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy I lemnished Wpectlondlvlslon. ' (�, (JI 7(ob
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID'(r'17
COMPENSATION INSURANCE ''Jr� r
(Thlssectlonneei not be completed tithe permit isforom hundreddollara SEWER-SANITARY-STORM EA.200FT. Date Receipt ` `)�•3
($100)orless.) WATER IiEATE)t W/VENT/ELECTR ENERGY FEE Y N
I mrtlty that In the performance of the work for which this permit is issuN,
I shall not employ any person in any manner.a as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California. Date PAID
ZZ Applicant NEWRESIDENTIAL PLMB, SQAT. Date Recei t#
O NOTICE TO APPLICANT:If,after ma king this Certificate of Exemption,you
F should become subject to the Workere'Compers.d..provisions of the Labor TOT '
N Code,you mast forthwith comply with such prowlam or thin permit shall E
> deemed revoked. _BU
LLI CONSTRUCTION LENDING AGENCY S SM_ 'Z
a.0 lherebyatflrmthxt there is a romtrvction lending agency for the perform- EL 'RI E - r
Z ante of the work for which this permit bL+sued(Sec.3097,Civ.C.) '
TOTAL:
PL GFE
LL t= Lendee.Addre. QTY. ,,. MECHANICAL PERA4IT FEE; ME HANI
OW Icertlty thatlhave read this applimllonand statethattheabovelnformatlon
CL iscomed,I agreeto comply with all city and county ordinances and state lawn PFRMITISSUANCE FEES
>. N relatinglobuildingconstmdion,andhercbyauthor emprmentalivesofthts
F U) city to enter upon the above-mentloned property for Inspection purposes. ALTERORADDTOMECH.
— (We)agree m save,indemnify and keep harmless the City of Cupertino a e Rf agalmtllabiatim,pdgment%c sandexpenseswhtchBUuy nywa AIRHANDNCUNIT(T010,000CFM) SUE
ai Id Citylncomequenceo grarain all q is -
(/Ir AIRf-IANDLINCUNIT(OVFR10,000CIM) CONSTRUCTIONC
B nature App ot/ ontractor Disc EXHAUST HOOD(W/DUCT) CONSTRUCT16ONT XPAID:
LSDISCLOSURE
pplicant ar 61,vbuilding attv pa or handle haeardous HEATING UNIT(TO 100,000 HIM Date RC Ci f#
al as defined by the Cupertino MuNclpal Code, pter 9.12,and the
Heahhxnd Safety Codr Setllon2S532U)7 HEATING UNIT(OVER tOQ000 BTU) T AL•
E-1Yea No -
{ Willthoapplkant orut .Wildingoccupant me equlpment'oidevkes VEM3LATIONFANGNGLERESID) ISSUANCE D F
rhicheMthaaerdousalrcontaminantaasdellnedbythc Bay Area Air ,
Q+ lily Managennnt District? BORER-COMP(3FIP OR 100,000 BTU)
I 4 Yes 9.Na _
have read the haza ous materials requirements under Chapter 6.95 of (OILER-C011p(OVER Ifilip0 BTU)
the CallfornialdealthkSafety Code,Senlons25505,25533and25534. I _ - I /n� -�
understand that lithe building does not currently have a tenant,that it Is my NEW RESIDENTIAL MECH. SQ.ET. % D
rapomibility to notify the occupant of the requirements which must be met -
PHor to issuance of a Certificate of Occupancy.
Owner.,authorized agent Date n DEC
TOTAL:
OFFICE COPY