22690APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
9I,dbg Addre,,:
PERMITNO.
22690
wan ante: one:
A A A
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
Q
contractors Name:LIo.No:
BUILDING-ELECTRICALMI BINC MECHAMCAL
CATEGORY
CONTROL M
Arch tett giaer. Lie. No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
Add.
PERMITISSUANCE
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcrosed under provisions of Chapter9(rommenc
Ingwlth Sectfon7000)of Divi,lon3ofthe B.,i.,and Profen .io Code,andmy
license Is In full force and effect.
License Clan Lic. N
APPLIANCESRESIDEN'TTAL
PANELS
]OBDESCRI"ITD
r�
7e�
Date Contractor
1�. /1
- r I �/ E
201-1000A.MP5
ARCHITECTS DECLARATION
I understand my plans shall be used as public recorda.
OVER IOOO AMPS
SQ. FT. FLOOR AREA S/SQ.FT.
SIGNS ELECTRICAL
Licensed Profeobn tl
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law forthe
A L E D I
SPFGIALCIRCUIT/MISC
TEMP. METER OR POLE INST.
Code: Any myw
following raqui sapction rmittoco Business andr,Impr Improve,
Countyng moarn. (SesapermittoConstessan ProfessionsCode: repair
a�
n n
17J
nystmmmprlortultsbsuance,ahom'quimstheappliantfwauchpermitto
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter 9(mmremsumg with Section 7000) of Dial.
slon3 ofthe Bumnessand Plefesaloa CedO.,that he h exempttherefromand
the bash for the alleged exemption. Any violation of Section 7MI.5 by any0[IILE'I
m
applicant fora permit subjects the applicant to a civil penalty of net are than
five hundred dollars hepr.
Mes,owaro( oche work,
my employees withended their n, fo
Compensation, work and the structure hoot Intended or for
POWER DEVICES
TVI �1
i/
SWIMMING POOL ELECTRIC A
-SWITCH FIXTURES
NEW RESIDENTIAL ELECTR SQ.FE
STORIES
TYPE CONSTRUCTION
70K Buldothe coffered
sale (Sec. 7044, Business and Profevbns Code: The Contractota License Law
does not apply to an owner of property who builds or improves themon,and
whodoessuch work himself orthrorgh his own employees, provided that such
OCC.GROUP
RE4.—UNITS
improvements are not intended oroffered forsak. If, however, thebullding or
Improvement bsold withnoneyearofcompletiogtheowner-builderwilf have
tr rden of proving that he did not build or Improve for purpose Clash.).
Lj L as owner of the property, am exclusively Contracting with licensedPERMIT
Contractors to construct the pmject (Sec. 7014, Business and Professions Cade:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who contracts fou such ploj-c with a
c%4aetor(s)licensed pursuant to the Contractor's Llmnse Law.
LJ I am exempt under Sec. B & P C for this mason
TOTAL:
QTy. PLUMBING PERMIT FEEFLOODZONE
ISSUANCE
1
ALTER DRAIN &VENT WATER
A(EA)
TPN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner Date
DRAINS FLOOR ROOF, AREA, COND.
FD(TURES PER TRAP
SANITARY Y N
RECEIPT M
WORILMAN COMPENSATION DECLARATION
hereby affirm that I have a certificate of consent to self -insure, or a
Al&
SCIiGOL TAX Y_ N_
lcate of Workers'Compsmation Insurance or a certified rore
copy theof (Sec.
380'Lab C.)
Policy N
RECEIPT If
GAS EA. SYSTEM -1 INCA OUTLETS
PARK FEE Y_ N
RECEIPT If
CETnv
certified Copy h hereby (hath ed.
y�enlfed copy h filed with the city inspection division.
j�
S
CAEA. SYSTEM-0VER4(EA)
GREASE/INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION ,
C. be he completed
(Phis section need oat completed Ithe pet( hfrn one hundred dollars
it
($1 Icorfy thof at
(certify employ an Penton any ante, so as to b cornhis permit is booed,
I shall not employ any person In any manner m u to become subject to the
W plicae CompewtlCn LawATER
s of California.CallfornlaDate
Applicant
PAID
Date Recei t#
SEWER-SANFrARYSIORM PA 200FT
WATER HEATER W/VENT/ELFCTR /�}�
w
ENERGYFEE Y N
PAID
SYS./TREATING
NEIN RESIDENTIAL PLMB. SQ}7,
NOTICETOAPPLICAM: f, after raking this CertKmtcof Exempii.ryou
should become subject to the Workees'Compensation provisions of the Labor
Code, you at forthwith comply with Ch provisions orthh parrot shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby orkfoffirm hatthcreharomt 6 hat lending agency 7, Civ. the perform-
once of the work for which this parrot h hwed (Sec. 3097, Civ. CJ
L<rders Name
Candela Address
1 cml(ythat I have read this applicatbnand wabthat theaboveln(omution
correct. I agree to comply with all city and County ordinances and state laws
re+atingtobu ngconst ctlon, and herebyauthwtze representatives ofthis
eitytoenter .the cmentkuxd rty for inspection purposes.
(We) a m save, 1 demnity and p harMem the City of Cupertino
against obi ties, judg fib, roatsande rax, wh2 moyin any wayacrnre
against id Ityln nequence o(the Hog ofthispermit.
Date Recej t#
TOTAL:
BUILDING FEE
TOTA
SEISMIC FEE
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
PERMITISSUANCE
MECHANICALFEE
FEES PAID:
ALTERORADDTOMECH.
AIRHANDUNCUNIT(TO10,000CFM)
Date Receipt#
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,(100CEM)
CONSTRUCTIONTAX
S
STiga.—t ppBcantractor Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUSTHOOD M/DUCT)
CONSTRUCTION TAX PAID:
HEATING LIME (TO 100,OD0 BTU)
Will the applicant orfuturebuilding oovpant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.12, and the
1Te❑alt .rd SlfstyCode, Secton25532h)?
Yea
Date Recei t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
Willthe applicant or❑futum building occupant use equipment ordevices
which emit hamedous air contaminants as defined by the Bay Area Air
Quality Management Distriet?
rl Yes (—I No
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
Nita
BOILER -COMP Ol-1 POR 100,000 BTU)
`'have readthehav ousmnertabrequimmnbunderChapter6.95of
the California Elealth & Safety Code, Sedioro 75505, 25533 and 75534. I
understand that if the building does net arrently have atenant, that ithmy
omponsibility to notify the occupant of the requirements which most be met
priortoL uanceofa CertificateofOmpancy.
,Ov
s1 k, I3
py
BOILER-COMP(OVER 100,000 BTU)
NEWRESIDENTIALMECH. SQ.FT.
Owner or authw+red agent #,rte
TO'TAG
ISSUED BY:
OFFICE COPY