22291APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
Ruuding Address:
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PERMIT NO.
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ant : one:
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDING. LECTRICA4PLUMBING-MEOHAMCAL
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c°nt•`'tto m. Na:
T B✓D!C % -333 y 9 L')
CATEGORY
CONTROL M
Architect/Engineer. k No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
j' y�
Address: �3 �/I p ),s
bi, ❑ ❑ ❑
IBJ
PERMTISSUANCE
LICENSEDCON CTOR'SDECLARATION
I hereby efilm that l am lbensed under provisions of Chapter 9(cmendc.
ingwlih Secilonfmxe fd.ffi, n3ofthe Buslnessand Pro(esslonsCode, and my
license is In full tom and effect.
Llcenx Clan Llcp
Date Contractor
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby a(fimn that ] am exempt from Ne Contractor's L
License for the
following oure a. (Section 70715, Busie...d Professions Code: My city or
ntywhlch requims a pemNt to mnstmd, alter, improve, demolbh,or mpalr
anystructum prlorto its lsxance, also requirestheapplIeset forsuch permit to
Ole a signed statement that he b licensed pursuant to the provisions of the
Contractor'sLicense Law (Chapter 9(cemmncing with Section 7000) of Divi-
slon 3 ofthe Buslnessand Pmfc iomCode) or that he b exempt therefromand
the baso for the alleged exemption. Any violation of Stolon 70315 by any
applicant fora permit subjects the applicant to a civil penalty of not mare than
five 1, as ed owner of the p0).
role
❑ 1, as owner of the property, or my employees with wage as offered
Busmen and Pmfnerty Code: The or imp Rots License Law
.1.(Sccompensa04k Ii ido the re. anorl4andthestmciurc Vnot Intended orrcense Law salesnot. apply
don nottauch loan owxrofprough who buinemporlmprovntbereoryand
who
ovem nts amwork hiase dedoroughed owns. If,he eprovidedlh t such ing or
improvementsarenot Intended arofco for aaie.If,however, gofer ilI have
improvement bsold within oncyear of completlorytheowner-W Bderwlll love
tfAIiurden of proving that he did not build or improve for purpose of sale.).
LJ I, as owner of the property, am exclusively contracting with licensed
centractms to westruct the project (Sec. 7044, Business and Professions Code:
The Contractors License Law does not apply to an owner of property who
Wilds or improves, thereat, and who contracts fee such ptojects with a
cgRtraet (s)licensed pursuant to the Contraciors License Law.
LJ I am exempt under Sec, B k P C for this reason
APPUANCESRESIDENTIAL
JOB DESCRIPTION
Il /
PANELS
UP TO 2DOAMIS
201-1000AMPS
OVER 1000 AMPS
SQ. Fr.
aaaFaaaLOOR AREA
�r D '
P U T� R
) Q
` /
S/SQ. FT.
_ SIGNS ELECTRICAL
SPECIALCIRCUIT/MISE
TEMP METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS-SWITCHES-FIXTURESt�c
VALUATION
O.0
NEW RESIDENTIAL ELECTR-SQ-FT.
STORIES
IWECONSTRUCI'ION
TOTAL:
QTY, PLUMBING PERMIT FEE
DCC.GROUP
ns. UNITS
PERMIT ISSUANCE
ALTER -DRAIN k VENT -WATER (FA)
FLOOD ZONE
APN
BACK FLOW PROTECT. DEVICE
'•'FEE SUMMARY
-
DRAINS. FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP1
SANITARY V N_
RECEIPTN
Owner - Date :
WORKMAN COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -Insure, or a
❑re
rtifluteof Workem'C=Np timlu=moramAitied copythemo((Sec.
W, lab C.)
Polity M
SCHOOL TAX Y N
RFGE[Pf M
GAS EA. SYSTEM -1 INC,IOUTLEfS
PARK FFR Y N
M
GAS EA. SYS EM -OVER 4 (EA)
Cam any
DING DI
BUIL DI VISION FEES
❑CertlOed copy is heed with the city
❑ CertRled ropy V filed with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
IThla section need not be completed if the permit V (orone hundred dollars
(510o)orlcss0
Imnot that to the par(ormanmoflhe work as to b. subject to
I shall not employ any person 1 saner as ss to become xbjett m the
the
Workcre'Compensatlon o If V. Date
AppllczNOHCnt
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
PAID
Date Recei t#
GREASETRAP
SEWER-SANITARYEA 2DOFr.
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
Date Recel t#
E.
WATER SYSTEM/TRFATING'
NEW RESIDENTIAL PLMB. SQFT.
NOTICE TO AI'PLIC makingthisCtion pro is Exemption, you
should msforth eWorkeit Cuch prooWims orchis perons it s Labor
Cada you meet (MhwRh comply with such provBiors orth6 permit shall be
deemed revoked.
. CONSTRUCTION LENDING AGENCY
Iherebyafflrmthatthem bacommadion leadingagency torthe perform-
ante, of the work for which this permit is heard (Sec. 3097, Clv. C.)
(ander'. Nam
Lender'sAddren
I mrtifythatlve readthts a
happhmtWnand oatethattheabove lnfomation
Is comeet.I agree to comply with all city and county ordinances and nate laws
relating to building mmtrudion, and hereby authorize representatives of this
city to enter upon the abovcmntiom'd property for Inspection purposes.
(We) agree to save Indemnify an d keep harmless the City of Cupertino
against llabllities K4 costs and expenses which may In any way accrue
agaimtsaidCuence oflhegrantingoft Permit
p/
/J /Date
TOTAL:
BUILDING
SEISMIC FEE
6
TOTAL:
ELECTRIC FEE
p
QTY. MECHANICAL PERMIT FEE
PERMIT ISSUANCE
PLUMBING FEE
MECHANICAL FEB
FEES PAID:
ALTER OR ADD TO MECH.
Date Receipt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:'
AIRHANDUNG UNIT (OVER IO,000CFM)
CONSTRUCTION TAX
Signator - cant/Contmcmr
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.IZ, and the
I lealth and Safety Cade Section 25532(a)?
❑ Ye• MN.
Will the applicant or future building occupant use equipment or devices
which emit hamrdous ab contaminants as defined by the Bay Area Air
Quality Matugemnl District?
Yes N No
'(have read the haza cus materials requimments under Chapter 6.95 of
- California Health k Safety Code, Sections 75505, 25533 and 75536, Iraleastd
pore ndthat ifthe building hcocupant not emquiyhave ments hich that It l9 my
responsibility to notify the occupant of the requirements which most be met
prior to ksuanm o(a Certiticate ot0<mpanry.
i
IXHAUS'r HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO IOD,OW BTU)
Date Reeei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
L
VENTILATION PAN (SINGLE RESID)
I$SU iJ '('E
i1R
AI
�� (4 Rga��Fs/s
�
ISSUED BY: Vx-�C�t1rT�"'V't1'r"'eJ
BOILER -COMP DEEPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEW RESIDENTIAL MECIr. SQ.Ff
Owner or authorized agent Data
TOTAL:
OFFICE COPY