22161 j APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMITNO.2161
Building Address: 2
wners one: A A
RIA) - SSS p CITY OF CUPERTINO-BUILDING DIVISION
Cono-anora Name: Lic.No: APPLICATIONI PERMIT "l�l
BUILDING ELECTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL#
Architect/Engineer. .Lk.No
QT'( 'ELECTRICPERMIT, FEE - "' BUILDWCx'•PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ �_
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under pravlsions of Chapter 9(mmmenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION -
ingwithSection7000)of Division3 ofthe BusimmandPmfessionsCodgand my
license b in full force and effect. PANELS
License Class Lk.#
Date Contractor Up TO 200AMF-S
ARCHITECTS DECLARATION 2014000 AMPS
qqq 0O l understand my plans shall be used sat public mearda. OVER 1000 AMPS - SQ.Fr.FLOOR AREA $/SQ.FT.
�j Licensed Professional - SIGNSELECTRICAL
6 w OWNER-BUILDER DECLARATION
- - SPECLLLCTRCUIT/MISC
Ihemowing ason,(hat l am 31.5,B from the d Pmfctorma Code;
Law for the
following reason.(Section 7011.5,Business and Professions Code:Any city it
O � TEMP.METER ORPOLE INST.
pE anystmcountympr oritoi pis ...e coonquiaatheap liantfrsuch,orrepalr
g a any.signere paler enta hat he is Bertrand
pursuant to the for inions of t e pOWU DEVICES
Q63k5 r V file a signed statement that he k r 9 loommunclog d pursuant it the pro10001 of the
O Con3ofthe ustrasLicensemul Low(Chapter9Ced0cothatwith Section10001Divi- SWIMMING TOOL ELECTRIC
slon3o(the Bvn(nosand Prafe vloreCode)orthathebexempttherefromand - VALUATION
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWITCHESHXTURES '
applicant fora permit subjects the applicant to a civil penalty of not more than
fieundred dollarsIg100). NEW RESIDENTIAL ELECTR SQ.FL. STORIES TYPE CONSTRUCTION
�n I,as owner of the property,or my employees with wages as their sok
compensation,will do the work and the structure V not intended or offered for
Is(Sec.704,Business,and Professions Code:The Contractor's License Law
does not apply to an owner of property who Wilds or improves them a,and OCC.GROUP RFS.UNITS
who doessuch work himself or through hismen employees,provided that such
a improvements are not Intended mattered for sale.If,however,the Wilding or TOTAL:
improvement III sold within oneyearofcompletbn,the owner-builderwill have ,
theTmen of provingthat he did not bund or Improve for purpose of sale). QTY �.'t ;:PLI71�dBINO ERMIT ' ':'`FEE.... FLOOD ZONE APN
j_j 4 ail owner of the property,am exclusively"contracting with licensed ppRMyf DANCE 1r��
contractors to construct the project(Sec 704,Business and Professions Code:
The Contractors License Use does not apply to an owner of property who ALTER-DRAIN AVENT-WATER(EA)
builds or improves thereon,and who contracts for such ptojects with a FEE'.SUMMARY'
tjjactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L.11 am exempt under Sec. B A P C for this'reasonOUTS I DE FEE 5
DRAINS A,COND.FLOOR ROOF,ARESANITARY Y N
Owner Date RF-CE'T#
WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have a certificate of consent to self-Insure,or a RECEI T#
.eifiuteofWoricers'Compesaatlonlnsuranceoncertified ropy,hw.of(Sec.
3800,Lab C.) GAS EA.SY5TEM-1INCA OUTLETS PARK FEE, Y N
Policy It GAS EA.SYSTEM-0VER 4(FA) RECEIPT#
Com any BUILDING DIVISION FEES
EcerHned copy la hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR - PLANCHECK FEE
❑Certified copy is filed with the city impection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2t0FT Date Recei t#
(Thlecectlon need not be ENSATI lithe permit infer one hundred dollars
($100)or lose') WATER HEATER W/VENT/ELECT'R Z�da ENERGY FEE Y N
I certifythat in the performance of thei work forwMdh this permit is Issued, -
I shall not employ any person In any manner m as to become subject to the - WATER SYSTEM/TREATING -
Workers'Compensation Laws of California.Date PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei f#
Z,p. NOTICE TO APPLICANT:If,after making this Certl(Icate o(Exemptlon,you
should become subject to the Workers'Comperuatlon provlalons of the Labor TOTAL:
Cr (2 Code,you most forthwith comply with such provisions orthis permit shall be
W >
deemed revoked. BUILDING
CL LENDING AGENCY SEISMIC FEE
1 hereby affirm that there ba construction lending agency forthe perform. ELECTRIC ELECTRIC FEE
Z anceoftheworkforwhlchthb permit is Issued(Sec.30W,CIv.C3 TOTAL. Lot
O O Lenders Name PLUMBING FEE LL a
F Lendere'Addmas QTY. �`•`ii' MECHAl iCAL'PBRMIT ,t E6E
OW Icertifythatlhavereadthlsapplicationandaakthattheabovefnformatim MECHANICAL FEE
1 'Is mood.l agree to comply with all city and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
). relating to building cosatrutlion,and herebyauthorize representatives ofthks
(— Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDIOMECH. Date Recel t#
_ (We)agree to save,Indemnify and keep harmless the City of Cupertino .- P
against11abl irl a,judgments,men and expenses which may In anyway accrue AIR HANDLING UNIT DO 10,000 CFM) SUBTOTAL:
against sal C mm� egrant of this permit.
r, AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signatureof AppBcanl/Contractor -Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE -
Willtheappllcantorfuwmbuildingoavpantstoreorhandiehazardous HEATING UNIT(TO 100,000 BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:❑Yea M No'
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air N{
Quality Management District? BOILER-COMP DEEP OR 100,CM BID) „a��
Yes n❑No -,av
have readthebaza'3ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) q
the California Health&Sudety Code,Sen Ions 25505,25533 and 2:534.]
understand that if the building does not corrently have a tenant,that it is my NEW RFSIDEN71AL MECH. SQ.FT �14f
responsibility to not ify the occupant of the requirements which most be met
prior to issuance of aCertiOcate o(Occupaney.•
Owner or authorized agent- Date ISSUEDBY.
< TOTAL:
OFFICE COPY