22068 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro'en Identification PERMIT NO.
Building Address: �wD - 22068
ner.
one: p
ante CITY OF CUPERTINO-BUILDING DIVISION �cq
• C",
an rectors Name: Uc.No: APPLICATION if PERMIT I'IC'Z�q
CATEGORY CONTROL.
r
BUILDING-BLECTRICALPLUMBINGMECHAMCAL
Archllen/Engimer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMRISSUANCF. ❑ � ❑
LICENSEDCONTRACTOR'S DECLARATION -
I hereby affirm that l am licensed under provisions of Chapter9(mmmenc APPLIANCES-RESIDENTIAL ]O _U<K TION
In ..i,Ln all f.roc and eff on3o(the Butlnenand l'ro(nsloneCode,end my
U.nbInfull form end c%If PANELS
License Clan Llcp L
Data Contractor —UP TO 20OAbU
ARCHITECTS DECLARATION 701-1000 AMPS
0Z I understand my plan shall be used as Public records. OVERIODOAMPS SQ.FT.FLOOR AREA S/SQ.Fr.
O
ULicensed Pmfenlorul SIGNSELECTRICAL
6, OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C -
7F' � Thercbyafflrm that lamexempt from the Contractor's License Law for the -
pp county which
ren.(&nlon703mBmmuctanter,Improve, Code:Anytltyor
0 2.'"� TITMP.METER OR POLE]NST. 4
ay
KEI mystmhmpdorlto iMrana vticeahomrqui lor,bnprovntforsbh,orretto
any atruduretatemeit that
alaensed rcrsuant in the revisions of to TOWER DEVICES
Ole a signed statement that he b licensed pursuant to the provisions of the
Oaf Contractors License Low(Chapter 9(commennngwith Section 7000)ofDivi-30 slon3ofthe Bfe
usinn...d PmssiorxCcde)mthat he b exempttherem
froand SWIMMING]'(IOL ELECTRIC VALU
$, the basis for the alleged exemption. Any violation of Sectio7031.5 by any OUTLEISSWITCHFSFIX'CURES
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollen($500). NEW RESIDCNEIAL ELECTR SQ.IT. STOI4I E 1 CTION
1,as owner of led property,or my employees with wages as their sok
compensation,will do the work,and the structure is not Intended or offend for
0 sale(Sec.7014,Buebeaniand Prdenioru Code:The Contractors License Law
ray$ don not apply to an ownerof pmpaty who buildsorimproves the.nand
whodaseuchwwrkhimselforthrvugh h(sownemployen,provided thatwch OCC.CROUIa RES.
improvements are not Intended orafferend for sale.IL however,thebulldlag or TOTAL:
impemementbsold within omrarofcompletb theowner-bullderwlll have
thA.kurden of pmving that he did not build or improve for purpose of sale.). QTY; PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to on ee re the project(S7694,Business and Professions Code:
'Ilse Contractor'.Limn.law don not apply to an owner of property who PETER-DRAIN&VENT-WATER(FA)
Wild. or Improves thereon,and who contract. for such p( n
oje .with a
ogR�Fagor(s)licensed pursuant to the Contractor'.License Law. FEE SUMMARY
LI I am exempt under See B k P C far this meaon BACK FLOW PROTECT.DEVICE
• Owner Data DRAINS FLOOR,ROOF,AREA.COND. SANITARY Y N—
WORKMAN COMPENSATION DECLARATION RECEIPT N
❑I hereby affirm that I have a certifirate of consent to self4asum,or a FIXTURES.PER TRAP' SCHOOL TAX Y N
mrtifimte of Worken'Compematlon lmumnce or a certified mpy thereof(sec. RECEIPT X
3900,Lab C.) `' paN GAS FA,SYSTEM-1 INCAOUTLETS - PARK FEE Y— N—
Pollry p OS t 7 p / �• RECEIPT X
GAS EA.SYSTEM-OVER 4(FA)
C. a^Y— G BUILDING DI VISION FE IS
eniiedri py b heed withtburnished. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CertJed copy b(lied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.XIOFT. Da[C RCCCI [#
Rhb.ection need not be completed lithe permit b(prone hundred dollars
($I00)rtifyth WATFAHEATE]i W/VENT/ELECTR ENERGYFEE Y N
111 not a.ployat In hepenor..in an tmannerhework so as to b comhis esuble.booed, —
I shall not employ eny.Lawn In any manner.u to become subject to the WATERSYST19N/TREATING
Worken'Compeneatlon Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQ.FT. Data Recei [k
Z.Q NOTICETO APPLICANT:]!,after making this Certificate of Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions or this permit shall be
7 deemed revoked. —.5DILDING FEE
CLC CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihereby affirm that there is a cowtrunion lending agenry for the perform- TOTAL ELECTRIC FEE
sure of the work for which this permit is haued(Sec.3097,Civ.CJ
OO MOO
feader'sName PLUMBING FEE
IL F Lcuder.Addrcn QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certifythatl have read thbappBnHon and statethatthe above information
brorren.Iagree tocomplywith all city muntyardlnances and gate laws PERMIT ISSUANCE FEES PAID:
} In relating to building construction,and hereby authorize representatives ofthb
)— Z city to enter upon theabovamenttoued property for inspection purposes. ALTERORADDTOMFLH. Date RCCei f#
— (We)agree to save,Ind emally an d keep harmless the City of Cupert Inc P
against Babllltles,jodg"m I meteandex meawhichmaylnanywayaccrue AIR HANDLING UNIT(TO 10,000 CIT]) SUBTOTAL:
ago Inst said City In coneaquenoe he nting of this permit.
1 �•/ � L5/ AIRHANDWNGUMT(OVER1f1,00DCIM) CONSTRUCTION TAX
ignaWAAppllahnit/Co r - e WO IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD0 MATERIALS DISCLOSURE
fut
Will theapplicant.1 ure
building occupant store or handle hazardous HEATING UNIT OD 100, BTM0 BDate RCCeIp[f?
material as deo ned by the Cupertino Municipal Cade,Chapter 9.1Z and the -
I1ealth and Safety Code Section 75537(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL'
Yes M No
Will the applicant or future building occupant an equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DA'Z'E
which emit hamnlous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3FB'OR IDLOW BTU)
4nYn N
have read the haze ou.omiterials requirements under Chapter 6.95 of BO➢-FR-COMP(OVFR 100,000 BTU) A�
the California Health&Safety Code,Stolons 75505,25533 and 75534.1 1� N�
understand that if the Wilding does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.Fr. APR
� y
responsibility to notify the occupant of the requirements which moat be met Q
prior to issuance of a Certificate of Omupa ncy. 11 � s19
Owner or authoriad agent - Date ISSUED BY:
TOTAL:
OFFICE COPY