22188 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuRding Address:
rD�s8 U ��.t��/lam/
rii arse: one:
7 -Q` p CITY OF CUPERTINO-BUILDINGDIVISION
Contra is Name; 17 yrs o: APPLICATION / PERMIT
12913 SBIALDINGELECTRICAI PLUMBING-MSCI IAMCAL CATEGORY CONTROL M
Architect/Engine Lie,No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION _
Ihereby Alum that l am licensed under provisions of Chapter 9(commenc- APPLIANCES.RESIDENTIAL. JOB DESCRIPiiuN
IngwithSedion7000)of Dlvisim3ofthe BustnessandProfnsionsCode,and my
license lam full force anddfed. PANELS
License Class Lu.a
Date Contractor
ARCHITECTS DECLARATION 201-I000AMPS
aszc I understand my Films shall be used es public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
E
C U Licensed Profc.t..l SIGNS ELECTRICAL
<M OWNBR•BUILDER DECLARATION SI'FOULCIRCUIT/MISE
L,�4 I hereby affirm that l am exempt from the Contractor's Llmow Law for the
pO following renon.(Section 7031.5,Business and Pmfes Amis Code:An cityor
rZF't �i countywhich requiresa permitt,comshud,alter,Improve,demolish,orreair 7FMP. MbTER OR POLE INSf.
`'3 .n anystmmm priortoits issuance,also requireslhe applicant for such permt to
file a signed statement that he b licensed pursuant to the provisions of the ]OWER DEVICES
3w Contractor's License Law(Chapter 9(commencingwlthSect1on70W)ofDlvl-
SWIMMING IDOL ELECTRIC
�OS the Wait for
Any)violation f exempt th31.5by y V TION
the blah far the permit
su exemption. Any violation of Section 7071.5 by any
«
applicant fora permit subjeds[he appllcan/loa dull pewltyof not more than OlJ7'['E7""''V✓ITCIIES77%'fl1RE5
five hundred dollars($.500).
❑1,as owner of the property,or my employees with wages ea their sole NEW RES DENT AL ELECTR_SQ.FT, STORIES, TYPE CONSTRUCTION
compensation,will do the work and the structure h not intended or offered for
q sale(Sec 7044,Business and Professions Code:The Contractors License law
3� does not apply to so owner of property who Wilde or improves thereon,and OCO.CROIRs PES.UNITS
whodn
osuchworkiden elforthwgh hisown employees,provided that such
Improvements are not Intended oraffered!orale.If,however,the W ilding or TOTAL:
improvement tssold withmoneyearefcempletion,the owner-builderwiil have
tlr*rden of proving that he did not Wild or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE PE55D ZONE APN
U L as..at of the property,am exclusively contracting with licensed
contradont.co.truck the project(Sec.70K Busmen and Professions Code: PERMIT ISSUANCE
The Contndor'.Lkerse Law don not apply to an owner of property who ALTIILDRAIN k VENT•WATER(EA)
Wild. or Improves thereon,and who contracts far such plajects with a
to, aria)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. R k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N -
Date RECERT M
WORK MAN COMPENSATION DECLARATION FIXTURES.PER TRAP LS,CD Y N
❑I hereby a(!mm that I have o lrou rate of consent to opy Chemo,ora s� RECEPT 0
38Mmittateo(Worken'CompewHwlnsurana ora certl(led copy thereof(Sec. GAS EA.SYSTEM-1'INCA OUTLETS PARKFFR Y N
P.li, ab CO&��` 7s— /T O RDEMPTN
PoliryR �/ }/ GAEA.SYSTEM-OVER4(EA)
C°rr' BUILDING DIV]SION Fr.ES
CS
ny Certified]copy is hereby te
❑CertBled copy is filed with
the
city tlty imps lion division. CREASE/INDUSTRL WASTE INTERCEPTOR PLANE}'IEGIC FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEINER- STORM E.A.200FT Date RC i tN
(0).tl ion need nd becomplded lithe Permit laforor�e hundred dollars
(51(U)orlyth) WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
]artl(ythat in the performance o(the work forwNch this permit bbsued, �� —
I shall not employ any person in any manner so as to become subject to the WATER SYSIFM/TREATING
Workera'Compenatlon Lwa ofGOfornla.Data PAID
O Z NOTICApplicant NEW RESIDENTIAL PLMB. SQFE Date Recel tk
Z O NOTICE TO APPLICAM:IL after making this Certificate of Exemption,you
Fshould become subject to the Workers''Comperaut ion provisions of the Labor TOTAL:
N Cade,you must forthwith comply with such provisions or this perrint shall be
dremed revoked. BIJILDING FEE
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyatfirmthat there is a mnatructlon lending agency for the perform ELECTRIC FEE
O
0 earn ofthe work for which this permit la Issued(Sec.3097,CIv.C.) TOTAL:
Landers Name PLUMBING FEE
IL I— Iendce.Addten QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1catlfythal l haveread thisappBationand Aatethat theabave Information
V ccned.l'sgom to comply with all dtyand county ordmancesand state laws PERMIT ISSUANCE FEES PAID:
} 1 relating to Wilding construction,and hereby authorize representatives ofthis
F N city to enter upon the abovamentimted property for inspection Purposes. ALIUORADDTOMECH.
Z (We)agree to save,Indemnify an of keep harmless the City of Cupertino Date Recei t#
V agaWllbbiHte,Rdgrocub,costs and expenses which may in any wayaccrue AIR HANDLING UNIT(TO IEODO CFM) SUBTOTAL:
cal Ityy(consaryenveo he gn, Ing a(W.permit.
f/ 1 AIR HANDLING UNIT(OVER 1B,Boo CFM) CONSTRUCTION TAX
A
Sigwtureof Appllan/ndd Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ARDOUS MATERIALS DISCLOSURE
Will the app ant or lulure building occupant store or handle hazardous HEATINGUMT(TO100,0DORM Date RCCei IN
material a defined by the Cupertino Munidpal Code,Chapter 9.12,and the
Health and SafetyCode Sedion2SS32(a)7 HEATING UNTT(OVER IOO,000 BTU) TOTAL: t.
❑Yrs M No
Will the applicant orfuture building occupant use equipment or devices VFNITLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
0 Quality Management DuMd2 BOILER-COMPOIIPOR 100,000 BTU)
4Yen ❑❑No 4.lAu'
have read the hazatlousmaterials requirementsunder Chapter 6.95of BOILER-COMP(OVER 100,000 BTU)
the CalBad t Health does
currently h 75stc...2that it y SQ I T A4 ���
understand Hsi lithebuildingtheacdon not the
haves tenant,that ltbm NEW RESIDENTIAL MECH. 1T. A
respotsiblll ndity theottvpant o(the requirements which most be M
prior to sof a Certificate ncy. IR?
Owne auth:rz.t D e TOTAL: ISSUED BY:
OFFICE COPY