22180 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Pro eq Identification PERMIT NO.
Building Address:
r�3z wet VAj . 22180
nen one:
CITY OF CUPERTINO-BUILDING DIVISION
Ca tractor'sName: LIc.No: APPLICATION /PERMIT J
Vfl K11� `l BUILDINGELECTRICAlePLUMBING-MECHAMCAL CATEGORY CONTROL
1W Architect/Engineer. LIC No:
Oily ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address pQCWTISSUANCE
LICENSED CONTRACTOR'S DECLARATION
om ❑ 1:1 hereby strum Bcesedunder
provisions ol .r APPLIANCSRFSIDENML JOB DFSCR1PlON
igwthSacWn70W0).fDivNo3ofhe Builnessand Prefoug..sCd,ardy -
`
Itt...1.ln full f end died. ��. PANES
License Lie.Y �p� ...�
D �Contnctor 'J —UP TO 2DOAM�S
ARCHITECPDECLARATION 201-1000 AMPS
ZO I understand my pkns ehaR be used u public records OVER 1000 AMT'SFT $/SQ.FT.
I4, Licensed Professional SIGNS ELECTRICAL 1 t R
06 OWNER-BUILDER DECLARATION �V/` /
L�j [hereby a(Orm thatlamexemptfromthe Contradole Llmnac law for the SI'ECULCI(CUIT/MISC
Z O^a following reason.(5e dion 70315,Business and Professions Code:Any city of j
O Z H TEMP.META OR POLE INST.
P countywhkh requbnsa permitroronstmct,ilteq Improve,denwLawforthempair
any.tm=mpdormlGismance,al mqulrestheappRuntfmr chper kto
Ofile a signed statement that he b licensed pursuant to the provisions of the ]OWER DEVICES
ati Contractors License Law(Chapter9(commencing with Section 7000)ofDist.
p,30 slap I ofthe Buslnessand ProfesslonsCeds)orthat he b exemptthertfromancl SbVA1MINGIWLELECTRIC r VALUATION
E5 O$ the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESFIXTURES 2)s CW
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars(f500). NEW RE9DEN71AL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
E]1,as owner of the property,or my employees with wages as their sok
mmpewtlon,willdoth,work,and theatructure k not Intended or offend(or
OIs(Sec.7064,Business and Protesslons Code:The Contractor.License Law
$$ dam not apply to an owner of property who Wilds or improves thereon,and OCQGRONa RFS.[INRs
whodoessuchwork himself orthrough hisown employee.,provided that such
Improvements are not Intended centered for sale.If.howe,egthebuilding or TOTAL:
improvement used withlnoneycarafcampleton,theowner-builderwlll have
lhaj�arden of proving that he did not build or Improve for purpose ofsals.). QTy. PLUMBING PERMIT FEE pLOpDIDNE APN
U L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
mntractan to construct the pmjM(Sec.7044,Business and No(cssians Code:
The Cmdcact is License law does not apply to an owner of property who
buALTER-DRAIN A VENT-WATER(EA)
Wilds or improves thereon,and who contracts
for such pkojecls with aFEE SUMMARY
cg0(pector(a)Banned pursuant to the Contndore License Law. BACK FLOW PROTECT.DEVICE
L�[am exempt under Sec. B k P C for this reason
'
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N OUTSIDE FEVS
Owner Date RECEIPPT#
WORK MAN COMPENSATION DECLARATION FIXTURESPERTRAP SCHOOL TAX Y N
❑I hereby affirm that I have acertificatelmatof consent d pytheuf m . RECEIPT N
cedlfi1.b C.) orken CompensationInsurance on certified copythemof(Secs GAS F.A.SYSITM-1 INCA OUTLETS PARK FEE Y N
Paltry Y CAS FA.SYSTQMAVF.R 6(EA) DING DI N
Com any BUILDING DIVISION PEES
�CedlOed copy V hereby e city
�Certi(ied copy V flied withth the dty inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ry
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANTCARYSTORM EA.2WFT. Date RE i t#
TThia section need ata be completed tithe permit b forone hundred dollars P
($100)orfess.) WATER HEATE(W/VENT/ELECTR ENERGYFEE Y N
I certify hatcep o the person
eny mar e,es as t ob ca pemnitis leaved,
I shall not employ any pereon in any manner at u to become abject to the WATER SYSTEM/TREATING
Woplican Compensstion Gsv.of Gll(ornla.Date PAID
O Z NOTICE
- Date Recei t#
Z Q NOTICE TO APPLICANT.If,after making this CenBlota of Exemption,you NEW RESIDENTIAL PLMB._SQ}T.
should became subject to the Workers''Comperoation provisions of the Labor TOTAL:
VI Code,you must forthwith comply with such provisions orthis permit shall be B A
deemed revoked.
00
dp CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is,a construction lending agency for the perform- ELECTRIC FEE
Z ante of the work for which this permit is issued f5rc.3097,Civ,C.) TOTAL:
CIO Lendcr'.Name PLUMBING FEE
IL H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OUJ I cedilythxt I havereacithisapplicationand Nate that theaboveleforrnatlon
6 larorred.I agreeto comply with all city and county ordinances and Natelaw. PFRMTTISSUANCE FEESPAID:
r N city to glob upon gm a vm my t1onrd property
rop authorize mprexnPurpos oRhk
z city(We)
ree to sae,Indemnify)an
propeharml Inspection Cit of Cu n. ALTER OR ADDTO MECH.
_ (rest)agree to nave,Indemnify an d keep harmless the i.. y Cupertino Date Receipt#
agaWt11ab11it1ee,Iadgmenn, .04nde n¢s which may In anywayamme AIR HANDWNC IINTf(TO 10,000 CFM) SUBTOTAL:
. a aWlaal In mo ant(ng dt spermit.
AIRHANDLING UNIT(OVER IB,BBBCFM) CONSTRUCTION TAX
Slgngumof Appucanl/ emu Dat F2(IiausT Hoop(W/DUCT) CONSTRUCTION TAX PAID:
LAZA OUS MATERIALS DISCLOSURE
Will the applies n[o uture building ottupant atom or fundic hazardous HEATING UNIT(TO 100,000 BTU)
materlalasdeMedbyihe Cupertino Munidp.ICode,Chapter9.lZ..dthc _ Date RCCCI t#
Health and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea No
Will the applicant or tum buildingoccupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air mntandmats as defined by the Bay Area Air
yThy Management District? BOILER-COMP DHP OR 100,0(0 BTU)
Yea N No t' /�JJ
have ria lee hazy fetyCDde,Sections
5,M3rChaplet 6.95 of BOILIR-COMP(OVLR 100,000 BTU) r tr�f f4
the understand
Heath kuilding oes Sedlamently have a3nan.ad 25536.1 f R1 o�C�t
responsibility
dytonthe the occupant not a requirmnts which
that it mats my NEW RESIDENTIAL MECH. SQ.FT u
responsibility to of.Cthe occupant of the requirements which must be met a..,
Friar to issuance ofaCertifkale ofOuvpanry. &'PI'➢1LH R.j�����'��� 1�/�_
Owner or authorized agent Date ISSUEDBY
TOTAL:
OFFICE COPY