22552 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification ,I /j `-`-O AJ 411
20PF]tMITN2
Bud2 5 5 2
Building
sr✓r.�S C� 61.01 mo,.�Dtct✓o
ame�,p ' one: A A
nem'1 C o L'*_A) 1 A�Q CITY OF CUPERTINO-BUILDING DIVISION / ^/
Co :•Name: Lie.No: APPLICATION I PERMIT CO 7
I, C: Y=hLL Q BUILDINGELBCTRICALPLUMBING-MECHANICAL CATEGORY C
Lk:. O QL M�{O
Architect/Imglneer. o COJ
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSIa CONTRACTOR'S DELLA RATION
)berets ion7O )ofDivsin3ofthe u rovbionsofCha r9(commnc- APPLIANCESRESIDENTUL — 'IIDNN
Y P Pt• JOB D� RB'CION
Ingwlth Section force
dalan3ofthe0uslnesand ProfeatlonsC-oris,and my T,Z. �VYxQnt
license is In bull force and died. PANELS
Llmnse Clas LICM
Date Contractor
ARCHITECT'S DECLARATION 701-1000 AMPS
Om OCC I understand my plans shaft be used as public record.. . OVER 1000 AMPS SQ.FF.FLOOR AREA $/SQ.FF.
Licensed Professional SIGNS ELECTMCAL J
6 OmWNER-BUILDER DECLARATION �.. I
�n SPECIAL CIl2CN7/M1SC /
7� 3Ihercbyalfim
that laexempt from the Contractor's LimnseLaw(orthe
qqqqfoBowing...(Seed..7031.5,Business and Professions Code:Any city or
F'�� cmntywhlchrequlresaper twmmtmo,alter,lmpmve,de=lish,orrepalr TEMP'MEfERORPOLE INST. `/ -p4'�
qqany structure prior to its Issuance,also requires the a ppfcant for such permit to (� E V II Y E"
6' µ file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES V
Gµ Contractors License Law(Chapter 9(rommencingwith Section 7000)ofDivi. SWIMMING POOL ELECTRIC
�0� de basis fo the essaalkge dexemption. Any violation
of exempt therefrom and E / ='- A A170
the basis for the alleged exemption. Any Wolatlon of Section 76315 by any �.(Svr` !'r`J L)J(-IJtar�
applicant for a permit subjectsthe applicant to a civil penalty and room than OUTLETS-SWITCHES-FIXTURES
µ Ove hundred dollasM. NEW RESIDENTIAL ELECTR SQFT. ,
I as owner of the property,oroy employees g k es as their soSTORIES TYPE CONSTRUCTION'CONSTRUCTION'yees with we
C 7 a compensation,willdothBusiness wwk.and the structure The
Contractoret Intended or offered Law
$ ❑ sale(Sec.7044,Business and f property
Code:The Contractor•Lirerue Law
$ rices not apply roa...... property who buildnem orimproovidedroryuch OCC.CROUP RES.UNITS
who does such work himsef arthrough his ownemployees,provided that such
Improvements are not intended oroffee d forsale.If,howeveq thebuilding or TOTAL:
improvement)wldwithinoneyvarofmmpldiogtheowner-bullderwillhave
tt(4Lurden of proving that he dWrwt bund or 4nprove for purpose ofsale.). QTY. PLUMBING PERMIT FEE pLOOD7ANE APN
Lf I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE /Ya
contractors to construct the project(Sec.7044,Business and Professions Code: Jy
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
bu Ids or Improve• thereon,and who contracts for such p(ojMs with a
mctm(s)Bmnsad pursuant to the Contractor'.Lirense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
61 am exempt under Sec. B k P C for this mason
•
DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y N_OUTSIDV FEES
Owner - Date RECEIPT 0
WOR WAN COMPENSATION DECLARATION pI(TURES PER TRAP SCHOOLTAX Y_ N
❑1 hereby.(flan that I have a mrtiRcate of consent to self-Insure,or a _ • RECEIPT R
maOcate of Worleera'Compevatienlvuranre ora codified ropythemof(See. GAS PA.SYSTEM-1 INC40UTLET$ PARK FEE Y N
3800,lab C.)
Po ry M — RECEIPT M
Cas GAS EA.SYSTEM-OVER4(EA)
Y BUILDING DIVISION FEES
Certified copy Is hnd with the cit. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
)Red copy V filed with the city Inspection dlvielon.
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID49IS
COMPENSATIONlaitt pee ( CE SEWER-SANITARY-STORM EA 700FT. Date Rccei t# Ala
� (Ihlssection need not becomplrted lithe permit d/wone hundred dollars
(81 I mrfify that
WATER HEATER W/VENT/[I.ECTR ENERGYFEE Y,Y_ N
)maty thato an person
any work.astocbthl.permit Is homed, 7-59E
—
1 shag not employ any person In any manner ao as to become subject to the WATCRSYSTEM/TREATING m /
Wwkers'Compenutlon laws of Offomla.Date PAID 8/6141 1�33yY
O Z Applicant , Date Rerni t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMIL SQFC,
t H N should become subject to the Worker•'Comperaation provision.ofthe Labor - TOTAL:
Code,you at forthwith comply with such provhioru orthis permit shall be
> deemed revoked. BUILDING •'E
W
z— CONSTRUCTION LENDING AGENCY SEISMIC FEE
(hereby affirm But there h a cotr
® uctionlendingagencyforthepedm-or
Z ance of the work for which this permit is Lssued(Sec.3097,Cly.C.) TOT , ELECTRIC FEE
(.) 2 Lenders N. PLUMBING PEE
LL F Lender'sAddrees QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertlfythatl have read thisappfmtionand statethatthe above information
h cormct.I agreeto comply with all city and county ordinances and stale law. PERMITISSUANCE FEESPAID:
} 5ft
1 relating to building construction,and hereby authodre representatives of this -
I— W city to enter upon the ab.vem..foned propertyforiespectlon purposes. ALTER OR ADDTOMECH.
2 (We)agree to save,indemnify an d keep harmless the City a Cupertino Date Reeei t#
(••�
against llabllltk.,Judgments,coasand expenses which may in anywayacerue AIRHANDLINCUNIT(TO10,000CFM) SUBTOTAL;
A " glctig l
dity Cin on encs of the granting of this permit AIRHANDLINC UNIT(OVER 10,000CFM). CONSTRUCTION TAX
Q0 . '
SignawmaApplicant/Contractor Dat EXHAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLISU14
Will the applicant or future building occupant store or handle huardous HEATING UNIT(TO 100,000 BTU) Date R0Ce1 t#
a material as defined bythe Cupertino Municipal Code,Chapter 9.1$and the
Health and Safety Cade Section 75537(a)l HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑Yea M No l ��x
Willtheappldcant or forum bcilding occupant use equlpment ordevices VENILATIONFAN(SINGLERESID) �W ISSUANCE DATE
which emit havardous air contaminant a.defined by the Bay Area Air
Quality Management District? BOILER-COMP OTB'OR 100,DM BTU)
1�Yca �No
ave read ihchu. oro materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,0(DBN)
ORVT
the ffend.Health A Safety Code,Sections 25505,75533 and 25534. 1 p /� Q
'understand that ffthe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SOFT, SEP�• 519Qt
respmoibdlity to notify the occupant of the requirements which must be rant
prior to issuance of a Ceaflmn,of Occupa racy. 4
Owner or authorized agent Date s \\
- TOTAL: ISSUED BY:_ _
OFFICE COPY