22601 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PELVBTNO.
Building Address: 22601
g • TT U e,
wnera one. A A, A
V N CITY OFCUPERTINO-BUILDING DIVISION ��pp
ontrsa°r,"//JJ--tmriI�e', Lie.No: APPLICATION I PERMIT t7'
to BUILDINGELECTRICALPLUMBIN' -MECHANICAL CATEGORY CONTROL N
Architect/Engineer: Lie.Nee
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PFRMITISSUANCE 2 ❑ ❑ ❑
LICFNS EDCONTRACTOR'S
order rDECLA RATION
I behsb if70RhatiamBcenaefthdBrprovlslonao(Gapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DFSCRfi'IiON
incense is in full 7lnes,a Dlvicet. ttheBusineasand ProlessionsCode,and my
Lkcrs la In full fprce and edea. PANELS �) \-r 2
Lice. Class _ Ee t- Za l� [�
Date Contractor ? K$iLfJILt L �s
ARCHITECTS DECLARATION 201.1000 AMPS 4+
20 I understand my plans shall be used.public records. OVER 1000 AMPS SQ.FT.FLOOR ARFA $/
0 L%enred Professional SIGNS ELECTRICAL D IN
65, OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC T E R
L ; Thereby affirmtOWNE exempt ER DE Contractor's License Law for the
oo following reason.(Seaton 7081.5,Business and Perfemioes Code:An cityor
F7HW county which requires a permit to construct,alter,Improve,derreelah,oresalr TEMP.METERORPOLEINST. 4lq/
ofa y`'egess anystm=m prient°its%avance,also requirestheappBcant for such permit to POWER DEVICES DATE
OC file a slgned statement that be Is licensed pursuant to the prohime,of the
a$ Contractors License law(Chapter 9(commencing with Section 7000)of Divi-gSW`MW' POOL ELECTRIC
s and Prafmnloro Code)orthat he%exempt therefromand VALUATION the basis for the alleged exemption. Any violation of Section 7031.5 by any
cion 3 ofthe Busines
applicant fora permit subjects the applicant to a civil penalty of net more than OUTLETS-SWITCHES-FIXTURES
a five hundred dollars($5007. NEW RESIDENTIAL ELECIR
00 �n ❑I,as owner at the property,or my employees with wages as their sok SQ'FT' STORIESTIE CONSTRUCTION
ompematlon,will do the work and the structure Is am Intended or offered for
O sale(Sec 7DK Business and Professions Code:The cmarsomes tiaras,Paw
5 does not apply to an owner of property who builds or Improv.thereon,and .
L whodoea such work himself or through his own employees,provided that such OCC GROUIr AESUNITS
Improvements are not intended oroffered for sale.If,however,the building or TOTAL: L c
Improvement%sold withinoneyearofcompleWmtheowner-buBderwill have
th rden of proving that he did not build or improve for purpose ofsale3. QTy. PLUMBING PERMIT FEE FLOOD ZONE
ppN
L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to roretrua the project(Sec.70K Business and Professions Code:
The Contractor'.License Law does net apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
Wilda or Improv.Hereon, and who contracts for such IrWinds with a
t[adruid licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for thin reason
Owner Date QL2I5112E FEES
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECmT N
E:],hereSCITOOL 7AX by affirm that I have a certificate of consent to selfnv
dre,ora FIXTURES PER TRAP Y N
certificate o(Workera'Comperwtlonlreurance ora certif%d ropythereof(Sec. RECEB' N
3800,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Policy If RECEIPT M
Com any GAS EA.SYSTEM-0VERd(EA)
�Ceaified copy is hereby furnished. BUILDING DIV 1SION I I:IiS
Certified copy%filed with the city Inspection division. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEM PFION FROM WORKERS' GREASE TRAP i PAID
COMPENSATION INSURANCE
(Thlaseaionneednmb me plaedifthepar t isforonehundreddollars SEWER-SANITARY-STORM EA.20017. Date Recef t#
($100)mmly
yth) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Ill am employ
o an7 person
In anythe work
everner for which this permit is Issued, —
I shall not employ any person In any manner ro u m become jilt to the WATER SYSTEM/,TREATING
WOrkefs'GOm tion la. Date y-fie-- i PAID
Z NOTICnt Date Reeei t#
NEW RESIDENTIAL PCMB.
Z O NOTICE!r-0 IC :I,a ng th%Certlficate of Exemption,you SQFL
Fshould bs,corte eubjad to the n'Compematlon prov%iow of the Labor TOTAL:
LUW Code,youmustfodhwithmmplywlthauchpmv io.orth%permitshatlbe
> deers drevoked. BUILDINGFEE
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyalflrm that them% ro
arawction lending agency for the perform ELECTRIC FEE =ODD Z ance ofthe work for which this permit%%sued(,3097,Civ.CJ TOTAL:
U2 LerWer'e Name PLUMBING FEE
LL H Lender's Addmas QTY. MECHANICAL PER FEE MECHANICAL PEE
O W Immo(ythatlhavemadth%appltraRonaMAatethauheaboveinfomution
C %correct.I agmen comply with all city and county ordinances and state laws PERMIT ISSUANCE 'h5 PAID:
} N mlating to building construction,and hereby authotic ropmeantatives°lthis
H Z city to enter upon the abovementloned property for Inspection purposes. ALTERORADDTOMECH.
— (We)agree to save,indemnify an d keep harmlea the City of Coped Ino Date Receipt#
against liabilities,judgments,costs and expenses which may In any wayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL-
-Ile
reg eClty consequence of of the grant Ing a this perrrdt.
-Ile_ Q �` AIR HANDLING UNIT(OVER IO,OJO CFM) CONSTRUCTION TAX
5lgrature of Applio�tL ontractor Date EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
TeX RDOUS MATERIALS DISCLOSURE
Will the applicant orfuWm building occupant store or handle hazanlous HEATING UNIT(TO 100,000 BTU) `3�i'-•O
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date ReCei t# aaZ
I and Safety Cade Section 25532(a)7 HEATING UNIT(OVER 1 00,000 BTIA
Yes �]No TOTAL:
j Will the applicant re future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air comamira nes as defined by the Bay Area Air
Quality Management District? BOILER-COMP pM'OR 100,0(p BTU) w
Yes II��No �®
have read the th&Safet materials requi 25505, SS33underand 25534,
1 of BOILER-COMP(OVER 100,000 BTU)
the Caftan%Health bSafety Code, mcurrentlyh vs,at and75534. I / C
understand that if the notify
the occupant emcurrentlyhichLthat it be men NEW RESIDENTIALMEIN. SQ.F7 �/ q
msporelbilityce a cerci "teontofthemquirerrenta which=at be met
prior to issuance da Cedificate of Occupancy. /5��+ p aPH
OF
Owner or authorized agent Uate �C%1 ISSUED BY:rlluzX91 V4
TOTAL: .3 s' —
OFFICE COPY