22882APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
s
CITY OF CUPERTINO-BUILDING DIVISIONeloraNa
APPLICATION / PERMITR/•�
BUILDING-ELECTRICALPLUMBING-MECIIANTCAL
PERMITNO.
n 2 n 8
11A Oji(lj(iG
Building Address:
oneo
5�era
/f Lic.No,
G
CATEGORY
CONTROL#
ect/Engineer. Lie No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO -
Addrcsa:
❑ Idl ❑ EJ
�}
I PERhITISSUANCE I v
Lm that BD CONTRACTOR'S DECLARATION
Ihereby aHtrm thatf er licensed oftheunder provisions afessio Chapter sC (commend
Ingwlth 1. Section d effeon3ofthe8uaineuand Professions Code, and my
ilunse intra (uHJorce�aptl effect. rj� �
Lic. or
LlaniR�7 ge C �Cmdr(ec_Tr(
ARCHITECTS DECLARATION
Iunderstand my phwehall be used as publicrerordw
Licensed Professional E�
OWNER -BUILDER DECLARATION
1 herebyaffirm that I am exempt from the Contradorb License law for the
toll.wingreason.0cdfon70115,BY•Ineesend Professions Code:Anydlyor
roontywhich rcquima pemdt tommtruc, alter, rov
Impe demolhh,orrepalr
anystr mmpdortottabeuame,aLsomquimstheappliuntforsuchper tto
file file a signed statement that he is licensed pursuant to the provisions; of the
Contractoe, License Law (Chapter 9 (commencing with Section 7000) of Divi-
lvl-
sion
sion3 of the Business and Professions Code)or that he Is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 70315 by dray
t ore than
applicant fora permit subjects the appecant to a civil penalty of nom
five hundred drofthepro
� e ad owner of the property, ar my employees with wages r their dole
compensation, Busdothe work and ion;; C dere h noHnteMed orcens offered Law
sale (Sec. 7044, Business and larofessbna Code: The Contractors License Law
does not apply to an owner of property who builds or improves l homes, and
whodon such work himself or through hisownemployees, provided that such
Improvements are not intended oroffered for sale. If, however, thebullding or
Improvement hsold withinoneyearofcompidlon, themmer-Wilderwlll have
ttic.Ifurden of proving that he did one Wed or improve for purpose of ule.).
u L as owner of the property, am exclusively contracting with licensed
contradom to construd the project (Sec. 7044, Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who
or improves thereon, and who contracts for such ptofedd with a
cgpj[actor(a) licensed pursuant to the Contractor's License Law.
L_I I am exemec pt under S 8 h P C for thin reason
CESRESIDENRTAL
JOB DESCRIPTION
'
cd..
PANELSAPPLIA
PANELS
701-1000 AMPS
OVERIODOAMPS
SQ. FT. FLOOR AREA
g L E D l
M P
L
$/ ,ET.
SIGNSELECTRICAL
LCItCIIIT/MISC
31�
TEMP METER ORPOLE INST.
POWER DEVICES,
SWIMMING POOL ELECTRIC
TSSWIL'C(iESFIXTIIRES
NEW RESIDENTIAL ELECTR �'�'
SI'OIUES
TYPE CONSTRUCTION
a0
TOTAL;
QTy, PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER -DRAIN hVENT-WATER (EM
OCC.GROIJP
RFS. UNITS
FLOOD ZONE
APN
BAIX]-LOW PROTECT. DEVICE
FEE SUMMARY
nllTqinE FEES
DRAINS A, COND. FLOOR ROOF, ARE
IgXTURFS PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
WOR KMAN COMPENSATION DECLARATION
❑L hereby affirm that 1 have a certificate of consent to •elf-Insureor
cedifimteo[Workers'Compemationhsuranmorsceklfkdcopylhereof0lec.
38W,Lb Cd
SCI100L TAX Y_ N_,
RECEI I N
GAS F.A.SYSIEMI WC.40ULLGTS
PARK EEE Y N
CAS FA. SYSTEM -OVER 4(EA)
Coman Y
BUILDING
HULLOING DI VISION FRES
d.
CertlBed copy in; hereby tumty Irupectlon divlxlon.
`��Cenifled copy b (fled with theecitlty
/`/l CERTIFICATE OF EREMPFION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed lithe permit h (Drone hundred dollars
(9100)°rfy that
I certify not that In an yedmort in any m nner so as tobeco permit Is ed to the I shall not employ any Lam In any manner at u to become subject to the
workers Compensation laws of California. Date
Applicant
NOTICE TO APPLICANT: If, ager making this Certificate of Exemption, you
should become subjectto the Workers' Compersatlon Provisions,of the Labor
Code, you must forthwith comply with such provisions orthh permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
I herebyaffirmthat there is a conatmdion lendingagency forthe perform
once of the work far which thin permit Is issued (Sec. 3097, Civ. C.)
Ianaef. Name
Lender's Address
Icekifythatl Wvemadthhapplimtionandshtethattheaboveinformation
N correct. I agree to comply with all tlty and county ordinances and Ante laws
relating to Wilding construction, and hereby authorize representatives of this;
city to enter upon the above�mentioned property for inspection purposes.
(We) a save, Indemnify an d keep harmless the City of Cupertino
against Illties, pdgments, mYsand ex which may In anyway accrue
a all d Clty In coneequenre of the ng w rich permit.
GREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECKFEE
PAID
Date RCCCI t#
D
GREASE TRAP
SEWER -SANITARY -STORM EA. "FF.
WATER HEATER W/VENT/EI,ECTR
ENERCYFEE Y N
PAID '
DRIC RCCCI t#
WATER SYSTEM/TREATING
NEWRE4DEN77AL PLMB. SO.IT.
TOTAL:
BUILD "E
SEISMIC FEE
TOTAL: '
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
DB[C RCCCI f#
P
ALR HANDLING UNIT (T01o,000 CFM)
SUBTOTAL'
a�/v
l4�S
AIR HANDLING UNIT (OVER IQOOOCFM)
CONSTRUCTION TAX
umofA cant/Co r ate
NAlA OUS MA TE RIA LS DISCLOSURE
Will the applicant or future building ocrupantstore or handle hazamoud
material as defined by the Cupertino Municipal Code, Chapter 9.1$ and the
Iieaithnnd Safety Ccd 7S
dion532(a)7
❑ Yea No
Will the applicant 6Ntum building occupant use equipment or devices
filch rout hazardous air contaouvnta as dented by the Bay Area Air
S�allty Management [��y107
4 Yaa ,pCl No
have read thein ar om mateHa mquiremcntsunderChapter6.95of
the Califomla Health A Safety Code, Sections 25505,25S33 and 75534. I
understand he building does not currently have a tenant, that it is my
repo dy to notify the occupant of rho rata which mustbeand
Eno ance of a Certlflute of0
IXFUUS'T HOOD (W/DUCT)
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
-
Date Receipt
HEATING UNIT (OVER 100000 BTU)
TOTAL:
��jj ee--y/11
VFNIILATION FAN (SINGLE RESID)
ISSUANCE DATE
p �e•Q
AMO
�}
OCT� jCII
Y I �, �J I�
ty t IG Berfinrt_
ISSUEDOY:
BOILER -COMP DEEP OR 100,000 BTU)
BOILER-COMP(OVER l00,000BTU)
NEW REMDENLIAL MECH. SQ.FT.
neroraut ge Date
TOTAL;
OFFICE COPY