22028APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN' ONLY
Building Pro'en Identification / -
Building Address:
PERMITNO.
22028
Owners Name:
5
one:
-
CITY OF CUPERTINO- BUILDING DIVISION
APPLICATION / PERMIT
BUILDING ELECTRICALI'LUMBINGMECHAMCAL
A
1: n'aName: Lle.Nre
CATEGORY
CO AT
- Nd
ArcM1itect/ gin r.
Se
Lic
o:
-
'QTY
ELECTRIC PERMIT
FEE
. BUILDING PERMIT INFO
Address: � d
1
ijy/, b�
PERMITISSUANCE
��j PLUMB
❑
LICENSED CONTRACTOR'S DE RATION
I hereby. l amlicensed under prov onsof Chapter9(mmmme-
Ingwlth Se ion70W)of Mi Mon3ofthe Budnossand ProfesslonsCode , and my
Licenskin full force and d(ect.
Date Cantnttor '
Date cClass Cont
ARCHITECPS DECLARATION
I understand my plans shall be used as public roared.
Licensed Profculonsl -
OWNER - BUILDER DECLARATION
I herebyaffirm that 1 am exempt from the Contractor's License Law for the
following reason.(Sedlon 7031.5, Business and Prefessbns Code: Any city or
countywhich mqulres a permit to mmtmd, alter, Improve, demolhh,°r mpair
anystmeture priortolts Issuance, also requiresthe applicant Gorsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the
Contractor's License Law(Chapter9(comrtenclog with Section 7000)°( Divl-
slon3 of the Business and Professions Code)orthat he h exempt therefromand
the bash for the alleged exemption. Any violation of Sedlon 7031.5 by any
applicant fora perms subjectatheappllcanttoacivll pemltyd not..than
Ove hundred dollars ($SM.
❑ I, as owner of the property, or my employees with wages as their sok
compensation, will d° the work and the structure h not intended or offered for
sale (Sec. 7044, Business and Professions Code: The Contractors Liaue Taw
don not apply to an owner of property who Wilds or improves thereon, and
whodoessuch work himself or through Ns own employees, provided that such
Improvement. are not Intended oroffered for sale. If, however thebulidlog or
Improvement hsold within one yearofcompielloo, the owner- Wilderwlll have
tt!a
LJ I, rden ofpmving that he did not build orlmprove for purpowofule).
as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such p(opds with a
cgR(Tapor(I) licensed pursuant to the Contndors License Law.
LI I am exempt under Sec B k P C for this mown
APPLIANCESRESIDENTIAL
- JOB DRSCRD'TION
`-�
PANELS
701 -1000
OVER1
SQ. Fr.ELODR ARE/^A�
Q V
�T'��
f /SQ.%FT�.
�V
SIGNSE IVI r
SPECIALC
TEMP METER ORI'OL
pOWER DEVICES
(,.1;
SWIMMINGIWL ELECTRIC
ETS-SWITCHES-FU(TURES
x�
VALLIATIONd G
L /� 0 UU
® 0 V
NEWRESIDENTIALELECTR SQFr.
fs
TY['E CONSIRIICTION
Q7Y,
TOTAL:
PLUMBING PERMIT
1'FRMLL LSSUANCE
ALTER -DRAIN kVENT -WATER (EA)
FEE
OCC. GROUT'
RES. UNITS
_
- FLOOD TONE
APN
BAIX FLOW PROTECT. DEVICE
FEE SUMMARY
nuT9111E FEES
DRAINS FLC)OR ROOF, AREA, COND.
F0(Tl1RES PER TRAP
SANITARY Y N
RECTIP It
Owner Date
WOR TION KMAN COMPENSA DECLARATION
❑1 hereby affirm that I have a nrtificate of consent to self -inar e, or a
certificate of Workeri C Insurance Compeation urance ora cedlfed ropythereo((Sec.
3800, Lab C.)
Policy N
SCIfOOL TA% Y_ N_
RECm'r N
CAS EA. SYSTEM -1 INC.40UTLETS
pARK FEE Y N
RECEBT N
GAS EA. SYSTEM -OVER 4 (EA)
y
BUILDING DI VISION ITES
Certified copy h hercbyth the cid.
❑ IOed ropy h tiled with the city Wpettlon division.
CERTIFICATE. OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(rhissection need not becompincd lfthepermit t.foronchund red dollars
(s1I mmlyth )
]artily that o the ree rson, i an ofthework
I shall not employ any person In any manner at u to become subjM to the
manner so as to b co permit c bo the
W plica'Compenution Laws °(Callfomh. Date
Applicant
NOTICE co APPLICANT: a aftermaking pe Certificate o(Exempt eLyou
shouldbemme subjectto the Wrrkert such posmlomprovhlourethe Lab or
Code, you must forthwith comply with such provisions resist. permit shall be
deemed rooked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there h a construction lendingagency forthepxl.m,
ance of the work for which this permit h Issued (Sec, 3097, Clv. C.)
Tender. Name
Lender. Address
I mrtifythat I haveread this application and state that theabove Information
ismrrect.I agree to comply with all city and county °rdlnances and stale laws'
relating to building cnuwction, and hereby authorize mpmearagives of this
city to enter upon the above- menti oned property for Wpedlon purposes.
(We) agree to save, Inderrudty a d keep harmless the City of Cupertino
agaluthabllld ,Y dgment. rests dexpenseswhlchmayinanywayacorus
gAost cal Ci i ronseq nceo he granting of this permit.
S Zl
CREASE /INDUSIRLWASIEINTERCEPTOR
P-Lftf41 -�K FEE
LL- .(I'1* --{� ��
PAID
Date Recef tit
GREASETRAP
SEWER SANRARY STORM EA. 700Fr.
WATER HEATER W /VENT /ELECTR
ENERGYFEE Y N
—.
PAID
Date Recei tN
_
WATER SYSTEM /TREATING
NEW RESIDENTIAL PLMB. SQFr.
TOTAL:
DI FEE
U /%
TOTAL:
SEISMIC FEE
ELECTRIC FEE
r
5
QTY.
MECHANICAL PERMIT
FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
�yt
CV
FEES PAID:
TER OR ADD TO MECH.
(J
�Q00
DRte RCCeI tN
P
AIR HANDLING UNIT(rO 10,000C}M)
- SUBTOTAL:
AIR HANDLING UNIT (OVER l0,000CFM)
CONSTRUCTION TAX
SI ns ! ppli cat Contra to
HAZAARDOU MATERIALSDISCLOSURE-
Wlllthea ppBcant orh own, building oavpant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.17, and the
I frzlth and Safety Code Section 75537(a)r
❑ Yea No
Will theappllcant or lure building ompant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Qu lily Ma rugement DisMd7
Yes No
Ihavcrcadthehazallous nuterla lsmquirementsunderChapter6.95of
the California Health k Safety Code, Sactions 25505, 75533 and 75534. 1
understand that iflhe building does notarently haveatcnanr that it is my
roprto issua c ofa Ctheoate of afthe panty, ircmente wM1lch be met
pricernsbsuance ofay theocuaOcmpa racy,
EmAuSTHODD(W /DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT(TO 100,000 BTU)
Date RCCeI (�
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENTILATION FAN(SINGLE RESID)
ISS ANCE DATE
/
f 1.. Ali
�..�
y 'N6_i`✓\
ISSUEDB �--'o
BOILER -COMP OfIP OR 100,DM BTU)
BORER.COMP(OVER100,oWB7U)
NEWRFSMENTIALMECH. SQ.FT
-
Owner or authorized agent Date
Data
TOTAL:
(
OFFICE COPY
J