22981 --=; APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification 4,�./��' r ^ 1 - PER.WTN`O. -
BulldingAddrcss: 26V�.� SU1J�SY' �„J�a '22981
wnmV b P,�S� nee: A
CITY OF CUPERTINO-BUILDING DIVISION
C " '.Na a=,Nn ' APPLICATION /PERMIT 11 —1
Arc- hit a/FggtI�'een� w '- Lk.No• _ BUILDMGELECTRICALPLUMBINGMECIUMCAL CATEGORY CONTROL
iVa+ "6 " '' +' ` i . BUILDING PIE
RMIT'INFO
QTY,, ,.( BLECTRICPERMIT I: .'FLE -
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION - ' -
Iherebyaffurnthat l am Bcrosed under provisions of Chapter 9 ficurnmene. APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ing with Semon 7000)0(D1Asi00 olthe Buslnessand professions Code,and my -
Ilcense is In full o{re egnnd PANFIS
- License Class `30'LIc.Msten. /0 a4'1 a O
Data /a / Contractor/- 85 UP TO 2DO AhMS
ARCHITECTS DECLARATION 201-I000AMPS
I understand my plan shall be used as public records. OVER 1000 AMPS TQ.FT.FLOOR AREA - $/SQ.Fr.
E zw Licensed Professional SICNS ELECTRICAL
Q OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC ^'
70' � Iherebyaflrenthat l am exempt from the Contractor's License raw for the _ a�
O 9 qq following reason:(Sectlon 7031.5,Business and Professions Code:Any city or i .
P f'ty co
county which requireas permit tomrect,alter,Improve,dem �E �olsh,or repair TEMP.METER OR POLE)NST.
O77 nystmRure prior to Its Issuance,also requires Neappllcent for such permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the P U I
w Contractors License Law(Chapter 9(mnmmncing with Section 7000)of Divi.
on .1�
SOS si3 of the Business and ProfessionsCode)orthat he b exempt therefromand SWIMMING]TOOL ELECTRIC. LUATION 1 '
the bass for the alleged exemption. Any violation of Section 7MI,5 by any j PATE
0 applicant for a permit subjects theapplkant too civil penalty of not more than OUTLETS-SWITCHES,
floc 1,as
delta.Ithepre v NEW RESIDENTIAL ELECTR .STORIES TYPE CONSTRUCTION
7 6 I,ate owner of the property,or my employees with wages as their sob
compensation,willdothe work and thestr acture is not Intended or offered for
' ❑ sate(Sac,70K Buslnessand Pmf.1r.Code:Th.Contractors License law
$ does not apply to an owner of property who builds or improves thereon and
who does.uch work himself orthrough hlsown employees,provided that such - ✓ OCC.GROUP RIS.UNITS
Improvements are not Intended oroffened forsale.If,howeveq thebuliding or TOTAL: -
Improvement sold within oneyearofcompletion,the ownerbullderwlll have
the burden of proving that he did not build or improve for purpose of sale.). QTY., ..,'-,PLUMBING PERMIT, •M1.),;i ",FE,E'. I•T.00D7ANE APN
Lf L as owner of the properly,am exclusively contracting with licensed ,
ISSUANCE
contractors b emstruct the project(Sec.7644,Business and Professions Code: -
The Contractors Lkense Law does nor apply to an owner of property who ALTER-DRAIN VENTWATER(EA)
Wilds or Improves lhenmn, and who contracts for such ptoject - •
s with a i,
c(bactor(s)licensed pursuant to the Contractors License Law. JEE,SUMMARY
L I am exempt under See. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE ITES
Owner Data
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
i WORKMAN COMPENSATION DECLARATION , RECEFT I
S PER TRAP - SCHOOL TAX Y N
❑I hereby affirm certificate I have acertificateconsentinwFIXTURE
le of consent to aei!-
re,or �m.M
mrtlRate o(Workers'Compensatlonlnsurana ora¢rtlfled ropy thereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS Y . N
3B00,Iab CJ / PARKFEE RECEIPT If
a Policy GAS-EA.SYSTEM-OVER 4(EA)
' Com ' BUILDING DIVISION FEE
'
�Certlflcd copy b hercbythte city � - GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK'FEE
�Certifed copy s filed with the sty inspection division.
CERTIFICATE OF EI(EM PT ION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWERSANTTARYSTORMEA200FT DatC Re i t#
(Thlssectlon need rad be completed lithe pemdt s for orm M1untlmd dollars _
(510f.aless.). . WATER HEATER W/VENT/ELFCTR ENERGY FEE Y N
I certify that In the performance of the work forwhich this permit s Issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSILM/TRTATING .
workereComponsationLaws ofCahtomb.Date PAID
0 Z Applicant
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.Fr. Date ReCCI t#
shouldbecomesubjeetto the Workers'Compensation provsiowof the Labor - 'TOTAL:
CC W Code,you must forthwith comply withsuch provsionamthb permit shall be
7' deemedIN "E revoked. -
IL G
CONSTRUCTION LENDING AGENCY SEISMIC FEE
ll I hereby affirm that there is a comtmdion lending agency for the perforne ELECTRIC FEE
Z anre of the werkfor which this permit s issued(Set 3097,Civ.C.) TOTAL: - _
U O Leaders Name PLUMBING FEE
U. f Icnders AddressQTY. ' .MECHANICAL.PERMIT - = FEE', MECHANICAL FEE
OW Icertlfythatl M1avereadthsspplicationmd statethat theabove Information
G Is correct.I agree to comply with all city and countyredinances and state laws PERMITISSUANCE FEES PAID: -
r N relatingto Wilding coratruction,and Fembyauthmuma ,,_,. tiveoflhb
I— Z city to enter upon the above-mentioned property for Inspection purpose. ALTER OR ADDTO MECH.
— (We)agree to save,IndemNfy an d keep harmless the City of Cupertino _ Date Recei tN
agaiear bllitles,judgments,costsand expenses which may in anywayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL:
agxlId City in ybitpermit.' con ens �'tling� -
-/Yg AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
vre of Appilcant/Contractor - Data D(IIAUS'r 1I0013(W/DUCT) CONSTRUCTION TAX PAID: . .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or hand le haeardous HEATING UNIT(TO 100,000 BTL
material as defined by the Cuperd no Municipal Code,Chapter 9.12,and theDate Reeei IN
Keith a rad Safety Code Section 25532(a)7 HEATING UNIT 100,000 BTU) - •TOTAL:
Q Ye. r]No
Will theappliant orfume building occupant usecquipmenl ordevices VENTILATION PAN(SINGLE RESID) ISS^UANCEDATB
which emit havardous air contaminants as defined by the Bay Area Air S
Quality Maragemenl District? BOILER-COMP f3HP OR 100,000BTU) Y „
n Ye No
have read the hav ous rtutedas requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 SIU) _ �0� 14
the Califemia Health&Safety Code,Sectiom 25505,2553)and 255 M.I q(;9
underk.nd that if the building does not currently have.tenant,that his my NEWRESIDENTIALMECH. � -SQ.Fr s999
r¢ponsibllity to notify the occupant o(the rcqulremente whicM1 must be met
priortolssuanceofa Cedifialeof Ocmpancy. 'e - 'CNY UV.�F-'..CCUyUPE*H I^INU c
Owner or authotived agent - Data , . �.r" ISSUIiDBY: _ F/
TOTALJ
OFFICE COPY