22714 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address:
22714
5 Ili c eaid
erg arM: 011e:
3-- CITY OF CUPERTINO-BUILDING DIVISION
c °N 9e APPLICATION / PERMIT
CO BUILDINGELECTRICALPLUMBING.MECHANICAL CATEGORY CONTROL N
Arch lect/Engineer. LM.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO .
Address PERhBTISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby ahelicensed under provis (otmnen APPLIANCESHESIDEN7IAL FSCRUf10N
IngwlthSMon7DO0)ofDivld=3oftheBuenessandPmfasionsCode,andmy 3013 D
license is In toR faroeand d(ect. PANELS"
License
�s LF Llr.N
Date se Z Contnaor
ARCHITECTS DECLARATION XII-1000 AMPS_
rem Z I underetand my plan shall be used as public record . /� OVER 1000 AMPS SQ.Ff.FLOOR AREA $/SQ.ET.
O
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SI'FfULCURCUIT/MIS[
ZF' 1hereby a(finothat l am exempt from the ContractorsLiansa Law for the
following mason.(Section 7031.5,Business and Professions Code:Any city or
O7FS.IP.METER OR POLE INST. ALE D
IciE coanlywhkh requlreea perNt to construct,alleplmpmve,demoliah,ormpalr
.a anystmct mpdortoit Ismance,abonquimstheapplimntforwapermitio POWER DEVICESfile a signed statement that he is licensed pursuant to the provisions of the
Owt•, Contractm'.License Law(Clot per9(mmmendngwith Section 7000)ofDivi.
I.,� g sion3oftheBuslnasand Profeaiov Coe)orthathel°exempttherefmmand SWIMMING POOL ELECTRIC V
the basis for the alleged exemption. Any violation of Section Illi LS by any OUTLETSSWITCHFSFI%TURES / r
< applicant fora permit subjects the applicant to a civil penalty ofnat morethan
five hundred dollars(SSM. yip
7 ❑E as ower of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQFI. R UCTION
mpensathm will do the work and thestmcturc b not Ntendd or offered(or
O .1.(Sec.7lMZ Rashness and Professions,Code:The Contractors License Law
SM does ndapply to an owner of property who Wilda or improves thereon,and OCC.GROUP RIS.UNITS
who doessuch work hlmsel(orthrough hls own employees,provided that such
improvements are not intended oroffered for sale.If,however,thebullding or TOTAL:
improvement hsaold within oneyearofmmpldlon,theowner-budderwlll have
t1U,isurden of proving that he did not Wild or improve for purpose ofsale.), QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT CE
ouromc ms to condroct the project(Sec.7014 Business and Professions Code:
The Contractor's License law does not apply to se owner M property who
Wilds or Improves thereon,and who contracts; for such ptoimta with a ALTER-
DRAIN&VENT-WATER(EA)
adw(s)Banmd pursuant to the Contractor'.Limn.Law. FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE nim�ainp FEES
Owner• Data DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y_ N RECETIC N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAIT SCI IDOL TAX Y N
❑L hereby affirorkern that I have o certificate of consent to copy
ythereo ora RECRUIT N
3800,certifab of Workers'Campevdlonlnsuranceora certl(kd copythercof(Sec. GAS EA.SYSTEM-I INC.4 OUTLET
Polis Isis C.) PARKF� Y_ N_
Co a GAS F.A.SYSTEM�OVER 4 MAE RECEBIfN
Cor^ ar BUILDING DIVISION FEES
[]Certified mpy ishercbytumecity GREASE/INDUSTAL WASTE INTERCEPTOR PLANCHECK FEE
Certified mpy V(Ikd with the city Inspection division. '
CERTIFICATE OF IXEM PIION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM E.A.200FT. Dale Recei 1#
Qhieeectlon sed rad be completed lithe permit l.lorone hundred dollars
($1M)otifyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
[certify that o the performance of the work f,as to
this permit Is c 4o the
I shell not employ any person In any manner so v to Wmme sabred to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z � NOTICE TOAPPLICANT.It,after making this Certificate ofExemption,you NEW RESIDENTIAL]LMB. SQFf. Data Receipt
H
should become aubjed to the Workers'Compensation provikimai o(the Labor TOTAL:
N
Code,you=at(orthwtth comply with such prov0lov orthis permit shalt be
deemed revoked. BUILDING FIE
0. c CONSTRUCTION LENDING SEISMIC FEE
I hereby affirnthzt there is a construction lending agency for the perform- ELECTRIC FEE
M Z ance of the work for which this permit la issued(Sec.3097,Civ.C.) TOTAL:
U O Lander'sName - PLUMBING FEE
IL I– Lender'.Address QTY. MECHANICAL PERMIT• FEE MECHANICAL FEE
O W Iovel(ythatl have read thisappllcatlonand statethatthe above Information
is corms.Iagree to comply withal)city and county ordinances and data Laws PERMIT ISSUANCE FEES PAID:
U)
2 relating to building construction,and hereby authorlu representatives of this
F city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDED MECH.
— (We)agree to save,indemnify an d keep harmiess the City of Cu pert Ino Date Recei tk
against liabilities,jldgments,mks and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
ga�l�id City in ronuqucn. ff the granting of this permit.
a 1 2tti1 /J � Hyl �d�_ /� �/ y� ALR rv.NDUNc UNIT(OVER loalocrh4) CONSTRUCTION TAX
Signatum of Applicart/CmVpior Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date ROceI til
material as defined by the Cupertino Municipal Cade,Chapter 9.1Z and the
Healthand SafetyCde Sectlon25532(a)? HEATING UNIT(OVER 100,000 BTIE) TOTAL: ' —
❑yea No
Will the spplianlor Lure Wilding occupant use equipment ordevlces VENTILATION PAN(SINGLE RESIDE ISSUANCE DATE
which emit hazardous air mntaMnants as defined by the Bay Area Air p� pp
QualityManagementDistrid? BOILER-COMP OFR'OR100,0MBTU) P A i D
4 Vea y No
have madthebu os,.materials requlrcmenta under Chapter 6.95 of BOILER-COMP(OVER100,D00 BTU)
the Gllfmla Health&Safety Code,Sections 25505,25533 and 25534. 1 NOV 21 1991
understand that ifthebullding do .not currently have tenant,that it is my NEW RESIDENTIAL MECH. SQFf.
responsibility to notify the occupant of the requirements which at be met /s 'cup]
prion uanmofacl/c camVoxcmpancy. CIIY ur t:rlI114U
��T j� IAS/ YN 41iaMI //•- </..%� /� {A�
Owner or authorized agen - Data 7DT ISSUED BY: �l�'�• 1
OFFICE COPY