22226 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Bulidin Address: -
S 22226
- aces: one: -
/ CITY OF CUPERTINO-BUILDING DIVISION - hq I
c°cats r Lie NAPPLICATION I PERMIT
BUILDINGELFiCTRICALPLIMBING-MECI1AMCAL CATEGORY CONTROL It
rchlt /Engineer. S Lir.Nin
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
I,L�l PLUMB MUCH
Address: PFRMITISSUANCR 11 1:1 [1LICENSED CONTRACTOR'S DECLARATION
gI hareby that am Bmned provisionsC9(mmmmc APPLANCESRESIDENTUL JOB DERII'1ON
lthSditon7000)ofgvsion3.(taxBosnee.and ProfessionsCode,and my
-
�9license Is In full form and effect. O PANELS
LlmnseC u LIeNYUP TO 200 AM
Date Cordractor '
RCHITECTS DECLARATION 211-1000 AMPS
QZ Iunderstand my plans shall be used u public rerorde. OVERIOWAMPS SQ.IT.FLOOR AREA s/SQ,FT.
l+Q� Cp LED IN
E Q F, Licensed Professional SIGNS ELECTRICAL !_\
e OWNER-BUILDER DECLARATION SPEC ALC RCU T/MLSC vi P U ?, E
owing ra(Brmthatla7exemplfromthe Contrsctor's Llmnae law lm the T a.�
Q following reason.(Section 7031.5,goalneae and Professlona Code:Any city or H
FIppp'uy countywhich requires a permit to construct,alter,Improve,demollsh,or repair TEMP.METER ORPOLE[NST. L/
O5 anystmmm pdorto its luuance,alsorequlm theappllmni for such permit to POWER DEVICES DATE v( 2.4/4?
GF77 fib le a signed statement that he licensed pursuant to the provisions of the
3wContractor's Llcenae Law(Chapter I(corromadag with Section 7000)of Owl- SWIMMMGPOOLELECTRIG
E, sion3oftheBuslneumdPm(essio®Code)orthathebemmptthemfmmand VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
4 applicantforapermitsubjectatheapplicanttoacivilpenallyofnotanrethan OO7LETSSWITCHESflXTURES S-000,0d
ofive dollars($500).
1,as owner
nerofthepro NEW RESIDENTIAL ELECTR SQFI'.
((((((ilililililil compensation,
villd the weak
andthey employees Is aminten ed as offered
foir saler STORIES TYPE CONSTRUCTION
C rom(Sec.70K Suldothew Professions
Cde:TheCntractro License
'S � ills(Sec.7094,Business and Profeuloru Code:The Contractors Llcenae Law
$ does not apply to an owner of property who Wilds or improves thereon,and OCC.CROUP RIS.UNITS
whodms uchworkhinuelforlhroughhlsownemplWm,providedthatweh
improvements are not Intended proffered for sale.If,however,thebullding or TOTAL:
Improvement b sold within omyearofcomplelloN the owner-W Bderwlll have
tl)ii_�urdan of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
LI L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractorsto commuct the project(See.7099,Businessand Professic ra Code:
The Contractors Lima.Law does not apply to an owner of property who ALTER-DRAIN Is VEVf-WATER(EA)
Wilds or Improves theeon,and who ronuses for such p(o*u with a
anBfactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
Lf I am exempt under Sec. B A P C for this reconOUTSI DE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMP aNSATION DECLARATION FD(TURES.PER TRAP SCHOOL'TAX Y N
❑I hereby affirm that I have a lmumne of mnunl to pythsure,ora ��.N
• 38M,mdiLab ofWorken Campensatlon Wuranm oramrtlfled copy therw((Sec. CAS PA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polk lab CJ
Policy N M
Corn GAS EA.SYSTEM-0VFR 1(EA) BUILDINGDING DI DI VIs1ON FEES
fied copy is hereby te
Caddied copy is flied withh the city inspection division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANITARYSTORM EA XN)FT Date ReCel
(This section need not be completed Rthe permit V - -
for hundred dollars Ptff
(alfX)oWATER HEATER W/VENT/ELECTH ENERGYFEE Y N
[certifyify that In the pedarnanm.(the work for which this permit blaeued, —
I shall not employ any person In any manner so u to become subjectto the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Data PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFI'. Date Recel tN
Z0 NOTICEco APPLICANT. Worm'fter Co this Certlfimteof isions theLao
should become subject to the Workers'Compensation provisions permit
the Labor TOTAL:
LU N dodgyau=at forthwith comply with such pmWloru arthls pemdt shall be BUILDING FEE
`J deemed revoked,
II.I — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IherebysfOrmthat there b a comtroction lending agency for the pedartry
ELECTRIC PEE
Z ance Lamlort N.aaa farwhich thio permitie Issued(Sec.3097,CIv,CJ TOTAL: PLUMBING FEE
LLO Lerdcr'.Addr -
LL L) lender'sAddres. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Iced lfythat I- -haveready with.11citlanand dcoutyordinaabove Information
1 lamrmct.lagrceto comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
N relatln'gtobulldlegcorutmctlon,and herebyauthorize representativesofther
r Z cltytoenterup.atWs e-menllamxd grope for Inspection purposes. ALTER OR ADDTOMMi.
_ (We)clime to ,.indemnify an a asst ty of cape At. Date Recei tq
against lU Iltie dgmenta, expen whi yin,a ayacente AIRHANDLINGUMT(TO10,000CFM) SUBTOTAL:
.gal d in cons yu of thr Ing e -
-� AIR HANDLING UNIT(OVER 10,000C w) CONSTRUCTION TAX
wwreof Apphenl/Con actor Data EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ortown,bulldingomspant store or handle hazardous HEATING UNIT(TO 100,WO BTU) Date Recei IM
material as defined by the Cupertino Municipal Code,Chapter 9.1 Z and the -
Iiealth and Safety Cody Section 75537(a)7 HEATING UNIT(OVER 100,000 BTUD TOTAL:
I Yes No
111 the appllmnt or wrc building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) 1$ DATE
which emit hazardous air contaminants as defined by the Bay Area Air
a lity Management District? BOILER-COMP 0HPOR 100,000 BTW
.
yes
No
havereadthe hax,inconts materials requirements under Chapter 6.95 of HOMER-COMP(OVER 100,000 BTU) ./s
the Callfamla Health k Safety Code,Sectors 75505,25533 and 75539. 1 ��� 0 �
understandthatnotihe fy
the ing occupant
of tcurrently equire encs whichq that It mets my NEW RESIDENTIAL MECH. SQ.IT.
underul{{sndt to notifythe occupant ret he rcqulhaveewhichmuat It met
priorlpAssuarmcfaCertlfimteofOnvpanry.
Owrkr or authorlmdagent Data 1551hDe'r\a
TOTAL:
OFFICE COPY