22820APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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PERMIT N22820
one:CITY
OF CUPERTI O -BUILDING DIVISION
APPLICATION If PERMIT
APPLICAITONSUBMIIIALUAIrm
D
tUwName:
sN .
CATEGORY
CONTROL N
gLc o.
BUILDING-ELFCTRICAI.PLUMBINCMDCHANICAL
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:�
PERN11TISSUANCE
1:1 1:1 El
ED CONTRACTOR'S DECLARATION
I herebyt I am Bcen3ofthe usin Wonao(Chapter Codc and my
IngwltI I fun7000)anDlWslan3o![he Businnsand ProfeaelonaCode,and my
license rein fuBf and d(M. c
Llansc Clam LIc. N_=_DWWA
APPLIANCFSRESIDENTIAL
JOB DFSCRBRl�
�
PANELS
Date Contra dor 2 0 / i'/•�''/
ARCHITECTED ZK— s
N
— UP TO 200 AhUS
�
pER
IODO
OVER 1000 AMPS
5Q. FT. FLOOR AREA
f/SQ. FT.
I undenland my plate shag be need as public records
c
SIGNSELECTRICAL I
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I amexempt from the Contractors License law for the
following ..a.(Sedlen7015, Busmemand Profembne Code: Anycltyer
county which requitesa permit tommtmci,alter, improve, demolish, orrepair
BPFGIALCB2CNT/MISC
7T2dP.ME1'FC11 POLE INS
a \V,
® IN ,
any assigned statementthatpursuant to the rovisiom of t e
Ole a signed statement that he m licensed pursuant to the proWlom of the
he I, licensed
Contractor's License Law (Ch. pler9(mmmencing with Section 7000) of Divi-
Sion 3 of Ne Business and I'rvfessbruCode) or that he le exempt therein,
the basis for the alleged exemption. Any violation of Section 7015 by any
applicant for a permit subjects the applicant to a civil penalty of not room than
fivehundred1, as owner of the pr .
L the property, or my employees with wages [herr dole
POWER DEVICES
fLLj`
C
SWIMMING POOL EL C
VALUATION
OU7IETSSW[TCHESFIJCNRES
NEW RESIDENTIAL ELECTR SQ.FT,
STORIES
TYPE CONSTRUCTION
compensation,
saowner will work, andthe r
nm Intended or offered for
Buldothe
sale (Sec apply Business endf dom Code:
Cotle: The Contractors eLaw
to property
don not apply tornImserofproughhis°buMborlmpmvnthereoRand
here
whodceseurh workhlmeel(orthreugh hleownemplayees, provldedthat such
OCC,GROUP
RES. UNITS
improvemrntdare not Intended ..offered for sale. It however, the building or
ImproverrenUssold within oneyearofcompletlon, theowner-bullderwill have
("rden°f proving that he did not build or Improve for purpose ofsale.).
u ; as owner of the property, am exclusively contracting with licensed
mra
ntractoto construct the project (Sm. 704, Business and Professions Code:
TOTAL:
QTY, PLUMBING PERMIT FEE
PERMIT ISSUANCE
FLOOD ZONE
APN
The Commences License Law don not apply to an owner of property who
builds or Improveon
Improves there, and who contracts for such p(ojects with a
cc p4actor(s) Bansed pursuant to the Contractors Linate Law.BAOC
IJ I am exempt under Sec B & P C for this reason
ALTER -DRAIN &VENT -WATER (EA)
FEE SUMMARY
FLOW PROTECT. DEVICE
- rrq
DRAINS FLOOR ROOF, AREA, CONE).
F7X7I]RES PER TRAP
SANITARY Y N
RECEIPT N
Owner Date
WOR KMAN COMPENSATION DECLARATION
[]I hereby affirm that I have a cerdfiate of consent to self
SCI{OOL TA% Y _
_ N
NN
-Insure, or
of Workers CompematlonlrounnamacertlTrod mpythereof Ecc.
3900,aLab
REC7i
GAS EA. SYSTEM -1 INC4 OUTLETS
PARKFEE Y_ N
Polley N
RECEIPT N
Cam any
GAS EA. SYSTEM -OVER 4 (EM
BUILDING DIVISION FEES
9CertlOed copy bhereby furnished.
Certified copy Is (fled with the city inspection division.
CREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF E)fEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sedlon need not he completed lithe permit bicrons hundred dollars
(1100)orlem.)
latifythatlntheyy (omunmo thew forwhichthiepemUtieblued,
PAID
Date Reed till
P
SEWER -SANITARY -STORM EA 20E)FI
WATER IIEAIFR W/VENT/EL[CTR
ENERGYFEE Y N
I hall at
I shall not employ Qy ere°n iq ryp e m m t -M to the
Workcni Camps i1 Laws of f°( ate
Applicant
,CANT: R, after gthb Certlfkale of mptlon, you
should become subject to the Workeri Compemation provisi w of the Labor
Code, you moat forthwith comply with such proviaioro orlhls permit shall be
deemed revoked.
PAID
Dale RCCCI IM
WATER SYSTEM/TREATING
NEW RESTDENI7AL PLMB.,_SQFT.
TOTAL:
FEE
TOTAL:
SEISMIC FEE
Cr
.BUILDING
CONSTRUCTION LENDING AGENCY
I hereby afflrmthat there is a corutmcilon lending agency forthe perform-
ance of the work for which this permit Is heard f9ee. 3097, Civ. C.)
Lenders NamePLUMBING
LenderdAdarem
wellythat I have read this application and statethattheabove information
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
FEE
MECHANICAL FEE
FEES PAID:
Is correct. I agree to complywith all city and county ordinances and Mate laws
PFRMRISSUANCE -
misting tobullding construction, and hereby authodae representatives of this
atytoenteru theabove-mentbned property for lmpedlon purposes.
(We) s rove, Indemmty an p harmless the City of Cupertino
agalmtljudgment,co a a nseswhic ymanywayaccrue
agairu ty In sen mmg oft s permit.
D
ALTERORADDTOMECFL
Date ReCCIPt#
AIR HANDLING UNIT (TO 10,000 CFM)
SUBTOTAL:
AIR HANDLING UNIT (OVER 10,00 CFM)
CONSTRUCTION TAX
51 tura of Applicant/Cont r Dam
D(ILAUSTHOOD(W/DL;Cn
CONSTRUCTION TAX PAID:
HAZARDOUS MATERoccupaU CLOSURE
Will the appBant or future building coops atore or handle hazardous
materlalasdefinedbythe Cupertino Munidpal Code,Chapter9.I7,and Me
Health and SafetyCodC,�Klon75537(a)7
❑ Y. No
7fF-ATING UMT(T010,000 BTU)
Date Recel Iii
IIEATING UNIT(OVER 100,00 BTI.!)
TOTAL:
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
s._
�B
Willtheapplkant fu re building occupant use equipment or devices
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management et ct7
4Yn o
haveread the FsmaterlalsrequirementsunderChapter6.95of
IIORER-COMP(3IR' OR 100,000 BTU)
BOILER -COW (OVIRIOD,000B71))
the Ca lifurnl alth&SafetyCode,Sediom25505,75533and25534.1
understand alit bu0dingdces conarmly have a tenant that It b my
�3�3 y
OCT N, 1Ja77
NEW RESIDENTIAL MTCH. SQ.I7.
respansl tyl not lfy the pa the requirements bleb most be mil
prior to a colaGi pang. xx
Ow rorauthonmdage Date
ISSUED BY:
TOTAL:
OFFICE COPY