22746 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22746
0
wnere a one:
G CITY OF CUPERTINO-BUILDING DIVISION
Cora ser an.: LIe.Ne: APPLICATION /PERMIT ����
BUILDINGELECTRICAL-PLUMBINGMECIIAMCAL CATEGORY CONTROL M
Architect/Engineer. Lie N¢
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ � ❑
LICF.NBF.D CONTRACTOR'S DECLARATION
I hereby affirm that l son llcemod under provisions of Chapter 9(commenc. APPLIANCIMRESIDENTIAL JOB DESCRIPTION
Inense I SectWn 7000).fforward
ofthe Buslnessand ProfeslonsCode,atnd my ,a
license la In full`lora and effect. PANELS
License CUm Lisp m51 � 7
Date Contractor .Jct Jn..r.�.t—"�..s�.syi
ARCHITECT'S DECLARATION 201-IIDO AMPS
q�qqqP++00Zp lundenland my plans shall he used as public rcmrda OVER 1lXp AMPS e,Q.FT.FLOD FAN
$/�.Ff•
i%z Licensed Professional SIGNS ELECTRICAL L E
at OWNER-BUILDER DECLARATION
In< mSPECIALCRCUIT/MLSC
t.
t I herebyalBrmlhal I am exempt lrothe Committees License Law for the
Q following reason.(Section 70715,Buslneu and Professions Code:Any city or Islas
K t' muntywhlchrequimsapert ttocomt d,alter,impmvelLL
,de= h,orrepair TEMP'METER ORPOLE INST.
°� anystruaure priortoite Issuance,also requireathe applicant f°rnuch permit to TC /O
E9 s file a signed statement that he b Ilcansed pursuant to the provisions of the POWER DEVLCES )ATE
Q6 3 w Contractor's License Taw(Chapter 9(commencing with Section 7000)of Dlvl-
Or^ sion3oftheBusiveuand Pm6admaCcde)mthat he isuam lherefromand SWIMMING POOL ELECI'[tIC VALUATION
rr 6 the basis for the alleged exemption. Any violation of Section 7031S by any OUTLETSSWITC}IF_ST7XTi1RE5.
a pplicantforapermitsubjedatheapplicanttoadullpenslly fnesmore Han
five,hundred dollars(SSfq). NEW RESSDENTTAL ELECTR
❑1,as owner of the property,or my employees with wages as their sole SQ'T' STORIES TYPE CONSTRUCTION
7� compeoution,willdothe work.and lhestructure is notintended or offered for
sale ecce.70K Business and Profeaskma Code:The Contractors License Law
duces nuc apply to an owner of property who Wilds or improves themes,and OCC,GROUT' RES.UNITS
who does such work himself or through hlsown employees,provlded that such
Improvements are not Intended oroffered forule.If,however,thebullding or - TOTAL:
ImprovemenW sold wlthlnooeyear°fcompiellon,lhe owner-builderwlll have
tfgkurden of proving that he did not build or Improve for purpose of ule.). QTY, PLUMBING PERMIT FEE FLOODTANE MIN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to anstmct the pmjed(Sec.7011,Business and Profuumd Cade:
The Contractors License Law dead net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon,and who contracts for such pkojects with
�lTador(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt under Sec. B k P C for this reason
•
OUTSIDE FI
Owner Dae
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N RECFIPTR
WORKMAN COMP aNSAT10N DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have o lrt m of consent to pythaum,ora RFL®'T N
e00,La eefWorkem'Cempensatlon lraunneora certified copy thereof(Sec. GAS EA.SYSTEM-17NC4 OUTLEfS PARK FEE Y N
3800,lab RECEIPT 9
Policy
M C '� L CAS FA.SYSTEM-OVER a(EA)
Com any a BUILI3INC DI VISION FEES
Ccrtlfle cpyI ere I ded. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certlfled copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER SAM'fARY
(Thlsaecilon need sat Wcomplded lfthe permitts for eve hundred dollars SMRMEA.200'T. Date Rccel to
(5100)or In®') WATER HEATER W/VENT/ELELTR ENERGYFEE Y N—
I I ertifythal m the performanceof the work lorwhlch this permit is Word,
I shall not employ any person In any manner se u to become subject to the WATrR SYSTEM/TRSATLNG
Worknm'Compenution La..fQhfurNa. Date PAID
O Z Applicant NEW RESIDENTIAL PCMB. Ff. Date RC'CGI IN
Z D N'OTTCETO APPLICANT:If,after making this CertBlateol Exemption,you —�
should be..subject to the Worker'Compensation provism. fthe Labor TOTAL:
CC N Code,you must forthwith comply with such provisions orthb permit shall be
> deemed revoked. BUILDING FEE
W
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there I..anstectton lend Ing agency for the perform. ELECTRIC FEE
0 Z Lander'.
N.
for which this permit is Issued(See.3097,Civ.C.) TOT
U O < .f t Name PLUMBING FEE
LL Lcndcrs Addres. QrY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I artlfythat l have mad this applicallnnand natethattheabove,information
N correct.I agree to comply with all city and countyordlnances and slate laws PERMITISSUANCE FEES PAI D:
). a relatleg to building construction,and hereby authorize representatives of this
F Z city to enter upon the abovcmenlionad property for Wpectlon purpose. ALIERORADDTOMFLH. Date ReCel IN
— (We)agree to save,inclemently an d kap harmless the City of Cupertino
against liabilities,judgment.,goner.and anpenxs which may in any wayaarue AIR HANDLING UNIT(TO 10,ODD CFM) SUBTOTAL:
against aid ey�,e °rt egranting ofthls permit. AIR HANDLING UNIT(OVER lo,"CFM) CONSTRUC170NTAX
&CJy 10-17-9'
5 atu®of Appilont/Contracctm, Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fitum building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RB[ei tN
material as defined by the Cupertino Municipal Code Chapter 9.1 b and the
I leakh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,0D BTU -FOIA
❑Yes No �[y�Ly�q�s
Cl
Will the appllcantoruture bulldingonvpant useequlpment ordevices VPNULATION PAN(SINGLE RESID) ry�Ql`.pyy,MNCE DATE
which emit haraedom air contaminants as defined by the Bay Area Air
Quality Management DiixtriR7 BOILER-COMP OHPOR 100,000 BTU)
4Yre nNe R :(
have read the Health
&Safety
Code,Se roquiltions 25505,25533 and 255 4, 1 of BOILER-CAMP(OVER I00,000 Bi1A
the Gllfornla Health hSafdy Code,Sections 75505,7$533 and 25534, 1
undcrstand that if the building dcee not currently have a tenant,that It is my NEW RESIDENTIAL MEIN. SQFf CRY
of r( nP t
responsibility to notify the oceupanteftherequirerreniawhkh must be mol ylaJ ) I}Qit,
Aorto Wuana oti Ifi occupant of
ser or authorized agent / v Date/
TOTAL: ISSIIGD BY: V
OFFICE COPY