22406APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
building Protect Identification
Build3as
11RMH NO.
22406
j1hre ham— pets¢:
CITY OFCUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUR.DINGLE.ECTRICALPLUMBINGMECHAMCAL
��nva r'a Name.In�
v <9
CATEGORY CONTRO N
Arehits#/Engl r. Llc No:
QTY ELECTRIC PERMIT ' FEE
BUILDING PERMIT INFO
Address:
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACT'OR'S DECLARATION
I hereby afflrmthat l am licensed under provoicea of Chapter 9(rommenc-
Ingwith Section7000)o(Division3ofthe Busimmand ProfmsipnsCede,andmy
licence la In fa deft#
Lire Cl tr
Co. _
Dale Contractor in u.
ARCHITECTS DECLARON
I understand my plana shall be used as public records. -
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt frosethe Contra#ore License Law for the
following reason. (Section 7071.5, Business and Professions Code: Any city or
cauntywhlch mqulma permit tommtma, alter, Improve, mo
delbh,ormpair
anystruMm prior to its Issuance, also requlrestheappliant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License law fChapter 9(commencing with Section 7000) of Divi-
Yee3 ofthe Bugesmand Profe sionsCode) orthat he h exempt therefromand
the bash for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjecathe applicant to a civil penalty of n# more than
five hundred dollars (S500).
nL.s owner of the property, or my employees with wages as their sole
compensation, will do the work and the structure b not intended or offered for
vie (Sec. 7044, Bu.ioeaa and Professions Code: The Contractor'. License haw
does not apply to an owner of property who builds or Improves t hereon,and
who does such work himself or through hisown employees, provided that such
Improvements are not Intended proffered forsale. If, however, thebuilding or
Improvement Issold withlnoneyearofcomplatlon,the owner-bullderwill have
ft.kurden of proving that he did not build or improve for purpose ofsale.).
u I, as owner of the property, am exclusively contracting with licensed
contractors to conslruet the project (Sea 7044, Business and Professions Code:
The Contract" b License law does not apply to an owner of property who
Wild. or improve therms, and who contracts for such pfoje#s with a
rgll�+#or(s) licensed pursuant to the Contractors License Law,
U I am exempt under Sec B k P C for this reason
APPLIANCES -RESIDENTIAL
)OB DESCRIPTION
,
PANELS
UP TO 200AM5
201-1000 AMPS
OVERIOOOAMPS
DE!" �.00"I"N
�T
n
l I
S/SQ. Fr.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MiSC
TEMP. METEROR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETSSWITCFI6SFIXTIRES
VALUATION
NEW RESIDENTIAL ELECTR SQBT.
STORIES
TYPE CONSTRUCTION
TOTAL:
QTY. " PLUMBING PERMIT FEE'.
OCC. GROUT'
RFS. UNUM
'-
PERMIT ISSUANCE
. ALTER -DRAIN kVENT-WATER (EA)
FLOOD ZONE
APN
FEE SUMMARY
BACK F7 -OW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, GOND.
FI%TURES PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a certifiate of consent to self -Insure, or a
ert c.leof WorkeraCompensa
ation Insurance orartifud ropy thereofeIec.
3800, Lab C3
PWIcyN li)PI ILF�7a ,-.
Com any
�chilled copy Is herebyfurnished.the city
ertifled copy h filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
(This section need nCOMPENSATION INSURANCE nor be completed if the permit h for one hundred dollar
(81OD) orless.)
Icecut thatln the person tan [he work so whichas to co ppmnlHclamed,
I shako not employ any person is any manner at m to become subject to the
Workern'Compensatlon Love of CalRornla. Date
ApplicaNOTICE
NOTICETOAPPLICANT: a ori making penCcrtnlate o(Exempt el you
Code, become subject to the Workers Compensationprovhis percthe Labor
Code, you reset forthwith comply with such provisions orthh permll shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
Iherebyaffirmthat there is a construction pending agency for the perform
ance of the work for which this permit is timed (Sec. 3097, Civ. C.)
Tandare Name
Lenders Addmss -
I certify that l have rcad this appliatbn and state that the abwe infomuti..
Is correct. I ugrm to comply with all city and county ordinances and Yate laws
misting to building construction, and hereby authorize representatives of thio
city to enter upon the above-mentioned propertyforiespe#ion purposes.
(We) agree to save, Ind emnlfy an d keep harmless the City of Cu penton
against Babilit lee, Judgments, costs and expenses which may In any way accrue
ago et dClty in consryuence f� the granting of this permit
9�
SCHOOL TAX Y N
RECEPfN
GAS F.A. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N_
RECER'1'p
CAS F.A.SYSTEM-OVER 4 (EA)
BUI LDING DIVISION FE IS
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
DatC RCCCI t#
P
GREASE TRAP
SEWER-SANITARY-STORMEA.200Ff.WATER
HEATER W/VENT/EI.ECTR
ENERGY FEE Y N
PAID
Dale Recei t#
WATER SYSTEM/TREATING
NEWRESIDENTfALPLMB. SQFr.
TOTAL:
BUILD ING FEE
SEISMIC FEE
TOTAL
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
YPERMITISSUANCE 151X_1
FEES PAID:
ALTER OR ADD TO MECH.
Date RCCCI t#
AIR HANDLING UNIT (TO 10,000 CIM)
SUBTOTAL:
AIR HANDLING UNIT (OVER i 0,(00 cm
CONSTRUCTION TAX "
IS t rcof Appliant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Wiiltheappllant orfuwmbu0dingoccupantsmmprhandleha rdoua
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
He❑alt Maenad Safety Code, Section 25532G)?
N.
Wllithe npplicantur❑futurebuildieg.pantuenequipmntordevim
which emit havardous air contaminants as defined by the Bay Area Air
Quality Management District?
4 Yes MN.
)wve read the b.Zlou. materials requirements under Chapter 6.95 of
the California Hl Ith k SafetyCode, Sections 75505, 25533 and 25534. I
understand that tithe building does net currently have atenant, that it is my
responsibility to notify the occupant of the requirements which moat be met
prior to Issuance of. Certificate of Occupancy.
EXHAUSTHOOD(W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT t00,W0BN)
Date RCCCI 1#
HEATING UNIT (OVER 100,000 BTUs
TOTA
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE
gi A' D
M
ovI�
Z'8 1n
�' 1a7
01:
BYA
BOILER-COMP(3HPOR 100,0(9 BTLB
BOILFB-COMP(OVE2 ioilwo BN)
NEW RESIDENTIAL MEIN. S'Q.Fr.
Owner or authorized agent Date
-ISSUED
TOTAL:
OFFICE COPY