22785 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed identification PERMIT NO.
Building Address,
0 22785_
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wnera came: Phone. A —At=A
GL C CITY OFCUPERTINO-BUILDING DIVISION
Co rador'.Name: Lic.No: APPLICATION /PERMIT
BUILDING-ELECTRICALPLUMBING.MWC MCAL CATEGORY CO
AmhRM/G nee '/ J) Lie.No:
/�// FZ MIR�S/,Ch,, fN_/ Q QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: �0/aaJ /Vo, A WL lfrRoc PERMIT ISSUANCE IBLOC ELECI PLUMB M�it
� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION I�•
IMrcby affvmthat lam lkeneed underprovldonsa(Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRBTION
ingwhfon ion3o(the BudnaandlrafealonsCode,and my
licenseeis 1.fun firma.maffect
PANELS
License Class UC.N
Date C..trader
ARCHITECPSDECLARATION 2014000 AMPS
0u7 I understand my plans sMRM used as public mcumIa OVER TWO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fa L Licensed professional ISIGNSELECTRICALD I N
<6 OWNER-BUILDER DECLARATION
In• ES SPECLILCI&CUIT,MLSC T E R
E- Thereby affirm that l am exempt from the Contractor's License Law for the
p0 FQ following caries.(Sectlan 70315,Business and Professions Code:My city or TEMP.METER ORPOLE INST.
td county which requires a permit to construct,alter,improve,
W demolL+h,or repair`'0 a any structure prior to Its issuance,also requlrea the applicant for such permit to POWER DEVICES 28h91
U file a signed statement that he Is licensed pursuant to the provisions of the�$ `wG Contractor's License Law SWIMMING POOL ELECTRIC UA ON
O sion3ofthe Bualnessacad Procatlov Ccde)orthat he is 5 exam thercfromand M ted basisfur the alleged exemption. Any violation o(Sectlont 70715 by any OUILETSSWIICHESFIXTURES W 0 a
FKK applicant for a permit subjects the applicant to a civil penalty of not more than 111
c-Fi five hundred dollars(5500). NEWRESIDENTIALELECTR �.F7. STORKS TYPE CONSTRUCTION
G1 ❑1,as owner of the property,or my employees with wages as their sole
/a compensation,will do the work,and the structure en not Intended or offered for
�,JNp sale(Bec.M0 Busineaand Profeafons Code:TMContcadoe.Licenselaw
p5$ does not apply to an owner of property who builds or improves thereon,and OCC.CROUP RIS.UNITS
who doessuch work him elf orthrrugh his own employees,provided that each
improvements arenot Intended oroRered formic.I(howeveq thebullding or TOTAL:
improvement en sold within oneyearof completioq ted owner-builderwlll have
Lbc ben of proving that he did not bund or improve for purpose mask.). QTY. PLUMBING PERMIT FEE
as owner of the property,am exclusively contracting with licensed FLOOD ZONE MIN
PERMIT ISSUANCE
otactors to construct ted project(Sit.70M,Businessami Professions Codes :
C. meters License law docs not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EM
da or Improves thereon,and who contracts for such ptojects with a
<gWfaaor0)licensed pursuant to the Contrador'.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
u I am exempt under Sec. B&P C far this reasonOUTSIDE FLES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Data RECEII'I'1'N
WORKMAN COMPENSATION DECLARATIONFLXNRES PER TRAP SCI{OOL TAX Y N_
❑1 hereby affirm that I have a certificate of consent to.el(-Insure,ora RECEIVE N
certificate ofWorkers'Compensation Insurance ora occulted copythemo((Sec.
3800,Lab C.) RECEIPT N
S GAEASYSTEM-1 WC.<OUTLETS PARK FEE Y N
SII
P.Bey I GAS EA.SYSTEM.OVER N(EA)
GBUILDING DI VISION PE[S
Go any
ffCedl(led copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified Copy en filed with the city inspection division.
CERTIFlGTE OF IXGREASE TRAP EMPFION FROM WORKERS' P
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2(IOFT. 1 t#
(fhlssMion need net M completed tithe permit la forov hundred dollars
(8100)ar leas) WATER HEATER W/VENT/ELECTR Y_ N_
I certify that in the performance ofthe work for which this permit Is issued,
I shall not employ any person In any runner so as to Mrom subject to the WATER SYSTEM/TREATING
Worker;Compensation Laws of California.Date PAID
O
F Z Applicant
TO FAIL'
t#
Z NOAPPLICAM:Bahermkng then Certnl .(Exemption,you NEW RESIDENTIAL PLMB, SQJ7 e
Oshould becomsubject to the Warken'Compensation provisions ofthe Labor
N
Code,you must forthwith comply with such provisions orthis permit shall be UFEE
w
W > docered revoked. la-
CONSTRUCFION LENDING AGENCY SE $E 11IEtiv'
tl IherebyafOrmtlut there Is a construction leadingagency(orthe perform TOTAL: EL
Z ance ofthe work forwhichthis permit en ensued(Sec.3097,CIV.C.) PLU F•
02 Lender's N.me
LL )= Leraer.Adareea QTY. MECHANICAL PERMIT ITE MECFIANICAL FEE
U Icedi(ylhat I have read this application and statethatthe above information
O W is correct.7 agree to comply with all city and county ordinances and date laws PFRMTTLSSUANCE FEES PAID:
Y (L relating to Wilding construction,and Mreby authorize representatives of this
F Z any to enter upon the aWvcmntinvd property for inspection Eau rposes. ALTERORADDTOMECH. Date RCC IPf#
_ (Na)agree to ave,Indemnify an d keep harmiea the City of Cu penton AIR HANDLING UNIT(TO 10,000 CFM)
against liabilities,pdgrrcnts,code and expenses which may In any way accrue SUBTO AG
agalvtsal in seque fthcgrantin ofthi croft.
AIR HANDU NG UNIT(OVER 10,000 CIM oPTICCONSTRUCTION TAX
Sig lumof Appncant/Conractor Date IXHAUST HOOD(W/DUC'D CONSTRUCTION TAX AID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haeardous HEATINGUNBT(TOI00,000BIIp Date Rece t
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCode Selion 25532(x)? HEATING UNIT(OVER 100,000 BTI!) TO
❑ Y. No
Will the applicant or utum building occupant use equfprrcnt or devices VENTILATION FAN(SINCLE RESID) I SUANCE DATE
which emit Mvardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COM?(3HP OR 100,000 BTU)
4 Yea No
Leve read the hav oro materials requirements under Chapter 6.95 of BOILER-COMP(OVER10),000 B711) ®� .a
1
the California lleaRh&SafetyCode,Secios,25505,25S33 and 2SS34. i 1991
M
understand that lithe building does not Currently have.tenant,tt it is my NEW RESIDENTIAL MECH. SQ.FT. v
responsibility to not the occupant of the requlmmnta which must be met
prior to noun nce of a Certificate of Occups ney. CIIY OF CUF'tlj IINU
Owner or authorized agent Date ISSUED BY
As�
TOTAL:
OFFICE COPY / `