22894 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
u Building Address 22894
wreyrs ante: - one.
��s(� CITY OF CUPERTINO BUILDING DIVISION
Cortr. nrsNams Lic.No. APPLICATION I PERMIT L 1
BUILDING-ELECTRICA4PLUMBlNC MSCI[AMCAL CATEGORY CONTROL 0
Architect/Engineer. Lie.Na
'Qrr ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: - PE2h9TISSUANCE U4J ELhUl PLUMB Mil
1:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby hSe&ioRrmthat lamsi=3 licensed fthe Bu nmand Pmf, ",r9(ammrnc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
it...i 1.full 7(100)or DiWfect. ofthe BuNneseand Prole on•Code,and my
ALI tierce isin full to. Conrad
` �� UP ELS
TO2
cense Lie#
ate Contract
ARCHITE DECLARATIO 201-IOOOAMPS
O I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.FT.
SIGNS ELECTRICAL V'
Licensed Professional J • -II
(�p+att OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M)SC �� '�� — 1�
I hercbyalnrm that l am exempt from the Contractor's License Law for the ,1 1E
zo following reason.(Section 70715,Business and Pmfeaslona Code:Any city or �"" ' - c' a
FZ � mantywhich requtma permlt to construct,alter,Improve,derrollah,or repair TPMP.MEfPR OR POLE INST. r
anystmct mprlortonslasrance,alsamquimstheappleantforsuchpermitto POWER DEVICES ATL
x'µ file a signed statement that he a licensed pursuant to the provisions of the
(yQµ Contractor's License Law(Chapter9(commencingwithSection7")ofDlvl-
0 3 O�n' SWIMMING POOL ELECTRIC
.Imn3of thegualncsa end Professions Cotle)orthat hebezemp[therefromand ALUATIO
�^g the basis for the alleged exemption. Any ,violation of Section 7071.5 by any OUTLET6SWITCHESFIXTURES # O 0
applicant fora permit subjeenthe applicant to a dvil penalty of not more than Il D
five hundred dollar,($5=.
NEW RESIDENTIAL ELECTR
�s ❑I,as owner will
the property,or my employees with wages r their dole �'�' SfOR[ES TYPE CONSTRUCTION
d.
compensation,Busine the s,And r and
ssion.vc e:s is The C Intended or offered
for
g O Axis(Sec. pply to Business,AndProfession.
propeiov Code:The or Improves
Iheeve Law
$ does not apply to an owner of property,who builds or Improves thereon,and OCC.GROUP RES.UNITS
CC..
who does•uts are ntfidelf or dedorough hir:owne.If,howeprovided thatsuch —g or
empmvementsarenot Intended earofc pl&ioe.If,however,the buildingve TOTAL:
improvement bwld withinovyearo(completio,theowner-bullderwlllluve
t Nen of proving that he did not build or Improve for purpmoofsals.). QTY. PLUMBING PERMIT FEE
e FIAOD7DNE APN
as owner m the property,am exclusively Business
contracting with licensedconPERMIT ISSUANCE
Tisa Contractor's
covtmct the project(Sec.apply
Business and Professions Code:
The Cror improves
es the Law Aced fiat apply tct an r such
of property who ALTER-DRAIN k VENT-WATER(EA)
Wilds t r improved thereon, and who contracts for ouch w.opm with e R
Cffactor(Wexem.e underuantrothe Contrector'd License Law. BApf FLOW PROTECT.DEVICE ' FEE SUMMARY
LJ I am exempt under Sec. B h P C for this reason "'-
DRAINS-FLOORROOF,AREA,COND. SANITARY YSANITARY Y N_
Owner Date RECEIPT
WORK MAN COMPENSATION DECLARATION FIXTURES PER TRAP SCI1OOLTAX Y N
QI hereby affirm that I have o Isent ate of consent to opytnwre,ora RECEIPT#
3800,mAlfiabte ofWarken'Compensatlonlnsunnce ora certlflM ropythemof f$ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
policy
lab CJ
i'oliq➢ GAS.EA.SYSTEM-OVER 4(EA) RING DI VISION FEES
#
CMy— BUILDING DI
[P Certified copy a heed with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANC-IECK FEE
�cemned ropy v plea with me dry inspection afvl.lon. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Re i t#
IThb aectlon need not be complcted I(the permit V forone hundred dollars
($10 codify that
WATERHEATEt W/VENT/ELECTR ENERGYFEE Y N
Ianoy emptor the person
mannerhe so as to oomhis enbject to thead, —
I Whale not employ any person In any manner so as to beeomv subject toted
Workers'Compensation LWWB of California. ATER SYSTEM/TREATING. Date PAID
0 Z Applicant
Z O NOTICETO APPLICANT.If,after nuking this Certificate of Excerptun,you NEW RESIDENTIAL PLMB. SQ.ET. Date Revel f#
M- eh.1dbecome..b)Mtothe Workem Compevtio pmvisiomofthe Labor TOTAL:
iW Coda,you must forthwith comply with such provisions or this permit shall be
j deemed revoked. -BUILDING
ILvCONSTRUCTION LENDING AGENCY SEISMIC FEE s
I herebyafflrmthat there esacotrvctlun lendingagency forthe perform ELECTRIC FEE
7 Z arm of the work for which this permit L Issued(See.3097,CIv.C.) TOTAL:
(„) O Lender.Name PLUMBING FEE
IL I"f Lender.Add mea QTY: MECHANICAL PERMIT FEE MECHANICAL FEE
OW Iartl/ythat l have read thisappllatlonand atatethatthe aboveinformution
4 iscorract.I agree to comply with all city and county ordinances and date laws PERMITISSUANCE FEES PAID:
7. relating to building construction,and hereby authorize representatives afthie
(— Z city to enter upon the abovcmentioned property for inspection purposes. ALTER OR ADD TO MECH. Dale ReCCI f#
_ .(We)agree to save,Indemnify an d keep harmless the City of Cupertino P
agalnstllabllltleW,judgments, Wand expense.which.yin A.yw.ya.A AIRHAN)LING UNIT(TO tOp00CPM) SUBTOTAL:
.go is City in nee the gra sting of W.pnnit
.l (I' AIR HANDLING UNIT(OVER IQODOCFM) CONSTRUCTION TAX
S reofA ant actor l/ Dat EXHAUST HOOD(W/DUCD CONSTRUCTION TAX PAID:
HAZARD US MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous EIGTING UNIT(TO 100,000 BN)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recei t#
Health and Safety Code Section 25531(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes r!No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) IS ATE
which emit hazard..air costa Mnants as defined by the Bay Arca At,
Quality Management District? BOILER-COMP OHPOR 100,000 BTU)
rj Yes ❑No
have read the hazardous nuterlals requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) (�
the Callfo.I.Health&SafetyCod,Sect1ov25505,25533and25534. I QV'i
understand that if the building does not cormatly have a tenant,that It is my NEWRESIDENDALMECH.
responsibility to notify the occupant of the mqulrement•which must be met
prior to issuance of a Certificate of Occupancy. - rk1EofCuDerul
Owner or authortzed agent Date `
TOTAL: ISSIIEDB
OFFICE COPY