22835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Binding Address: 22835_
Owner'sName: p o e:
vn an SOC A
CITY OF CUPERTIN46UILDING DIVISION
centra ac u LieNo: APPLICATION /PERMIT
0. 7� BUILDING-ELECTRICAL PLUMBING-MECFIANICAL CAIPLORY CONTROL# '
Architect/Engineer. Lie No:
On ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE - ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOB DFSCRI'TION
InenseI infulI70W)ofdoffeon3 ofthe Busiraresand Profs IansCode,and my ..X
license is In(ul arae and c.t PANELS s
License Cla LIc.X
Date Contactor '
ARCHITECTS DECLARATION - 701-1000 AMPS
�
9 CZ re
I understand my plans shall be used as public cords. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.Q(7 Licensed Professional SIGNSELECTRICAL LED i N
Qa OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M1SC k� ■ a E
2F'yd� Ihercbyalfirm ttutlam exempt from the Contractor's License Law for the 1V U
❑❑ following reason.(Section 70315,Business and Professions Code:Any city or
— countywhichrequlresaper ttommtmL%aitegUpmve,demolbh,ormpair TEMP.METER OR TOLE INST.
any.trunure prior mite Wuamxe also requimethe applicant forsuch permit to
(� file a signed statement that he b licensed pursuant to the provisions of the POWER DEVICES DA nw-�
3 sc� CmmutoleLicenseLsw(Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC VALUATION
SOS sionlolthe Buslneseand Ptof.lom Code)orthathelsexempttherclromand
Q the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHFSFIXfURES
applicant for a permit subjects the applicant to a civil penalty of not erurethan
$ live 1, ao owndoler
of thepro NEW RESIDENTIAL ELECTR SQ.FC, STORIES TYPECONSTRUCTION
e saowner o!the property,or my employees with wages r thele sale
7< ,
compensation,Ihlldothe work and the ssion,mamre ion Contended License d for
Law
O dile(Sec.apply
to ainowand f property who
Code:The Contactors Llreme Law
$$ and
whorldoes tapply torn owner ofprooghh1sonempds or improves yces,povided thereon, OCC.GROUP RFS,UNITS
who work r men odd m ler hlsownemployeea,providedthat such
Imprownssntaarenot Intended earofc pleioe.If,however, cider ilI have TOTAL:
Improvement bsold withlnormycarofcomplellon,the owner-bulderwlllhsve
the burdenodproving that he did nolbuldorimproveforpurposeofsale.). QTY, PLUMBING PERMIT FEE
0 L as owner of the property,am exclusively contracting with nsed FLOOD ZONE APN
lice
contractors to crnsiruct the project(Sec,7014,Business and Professions Code: PERMIT ISSUANCE
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such pSrjrcts with a _
c75actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
IJ I am exempt under Sec B k P C for this reason
OUTSInP Ft IN
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Owner Date RECEIPT_ NX
WORKMAN COMPENSATION DECLARATION p),%T(TI(pg PER TRAP SCHOOLTAX Y N
QI hereby affirm that 1 have o certlfla c of consent to copy
tnmre,oracedRECEIPT X
'00,Lle ab
lraunnce ora rerti(kd ropythereof(Esc. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800.Lab Cd
Policy# GAS EA.SYSTEM-OVER 4(EA) RECEIPT If
Com any BUILDING DIVISIONFEES
OCertified copy is herebyfurnished.
the
GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
�Cetllfied copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE ND'ARY-STORM EA. Date RCtti 1#
UhbMat bmi
sion need ee completed if the pert b rs for ohundred dollars .Wl D
(5100 or less.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I performance that In the perfaunce of the work for which this permit is issued, —
I shall not employ any person In any manner eo as to become subject to the WATERYSTEM/TREATING S
Workere'Compeneatlon lawn o(Callfornla.Date - PAID
-
Z Q Acant
NOTICE TOAPPLICANT:B,aBcr making this Ccrtlllate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date 'RCceI 1#
CC (2
should become subject to the Workers'Compensat[on provisions of the Labor TOTAL:
Code,You=atforthwith comply with such pmvlsbmorthis permit shall be
> deemed revoked.
BUILDING LU
C - CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lend Ing agency for the perform TOTAL. ELECTRIC FEE '
Z anm of the work for which this permit b issued(Sec.3097,Civ.CJ - PLUMBING FEE
V O Lendcr's Na rrc a
LL — eraser.Aadreaa Q'Y. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertilythat l havercad this appllatlonand state thattheabowWormatlon
1 1s;correct.t agree to comply with al city and county ordloances and orate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building construction,and hereby authorize representatives ofthb
)— Z city to enter upon the above-montionei property for inspection purposes. ALTERORADDTOMECH. Date ReCei [#
— (We)agree to save,Ind emnlfy an d keep harmle,the City of Cu part Ino P
against liabilities,/tdgmants,cortsand expenses which may In any wayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL,
sgaimtsai Cltyln nsequermeofthegranting ofthlspermlt
n AIR HANDLING UNIT(OVER 10,0DOCFM) CONSTRUCTION TAX
Slgnatureof Appllant 5mract Date 1 ExHAUSf HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAURDOU ATERIALSDISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Data RCCCi I#
metcmI as defined by the Cupertino Municipal Code,Chapter 9.1$and the
Iica llh and Safety Code Section 75533(a)7 HEATING UNIT(OVER 100,000 BTU) TOTA
❑ Yesin
Na
Willtheappliant oruture building occupant use equipment ordevims VENTILATION FAN(SINGLE RESID) ISSUANCE DATE j
which emit hazardous air contaminants as defined by the Bay Area Air
• Quality Managnmcm Dbtrltl7 BOILER-COMP OFI'OR 100,000 BTU)
Yes n❑No
have oia theth&S 1mycoedale tions 25505,25533 and 255re.95 of BOILER-COMP(OVER 100,000 BTU)
theerstan thatathebSofetyCode,Sect1owntlyhveatennd,that 1 OCT81991
understand that lithe theonupant not erequire encs which
that it mot NEW RESIDENTIAL MECH. SQ.R
responsibility to Issuance
c of a Certificate
of of panty.requirements which must be met
prior to lesuance of a Certificate of Occopancy.
C1
Owner or authorized agent Date
TOTAL: ISSUED BY:
OFFICE COPY