22509 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proem Identification 7 PERMIT NO.
bullet a Address: 22509
time me. CITY OF CUPERTIN68UILDING DIVISION
Contreaor'sName: P1fp4, ,bA1 Lie.No: gppLICATION /PERMIT �3�1
v– A5 7BUILDING ELFCTRICALPLUMBINC MECHANICAL CATEGORY CONTROL N
Architect/Enginer. Lie No:
Q'IY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addresv: PERMITISSUANCE ❑ ❑ N ❑
LICENSED ED CONTRACTOR'S DECLARATION
I hereby aon700Ihatlam.i.36(he under BuslcaseaemofChapteredrand(comment APPLIANCESRESTDENTIAL )00 DFSCRIIaTION
ingwlth5ealull form of Dlviefon3 afthe Buelneuand Profeta omCode,and my
license le In toll(orae and affect. –. PANELS
License Clam�LI.N S 2"
Date Contractor —Up TO 2DO AMPS
ARCHITECT'S DECLARATION 301-1000 AMPS
Q❑O I understand my plamalullbe used m public records OVER 1000AMPS SQ.1•T.FLOOR AREA $/SQ.FF.
k t, Licensed Professional SIGNSELECTRICAL
11 DI OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISE
2s, 6 IherebyafRrmthatI amexempt fromthe Contramerb Llmose Lawforthe
following reason.(Section 7131.5,Business and Professions Code:Any city or
county which requires a permit to construct,alter,Improve,demolish,or repair 7FMP.METER OR POLE IN ST.
anystrudure prlortolb Wuance,also requlrestheapplinnt forsuch permit to POWER DEVICES
file a signed statement that he Is Ilmnsed pursuant to the provision of the -
3 w Contractor's License Law(Chapter 9(commencing with Seaton 7000)of Dive- SWIMMING IA70L ELECTRIC
SOS elon3ofthe Business and Professlore Code)or that he b exempt therefromand VALUATION
the basis for the alleged exemption. Any violation of Section 70715 by any
0�A•
applicant for a peJl subjects the applicant to a civil penalty of not more than OUTLE7SSWITCIiESFTXTURsubjects
Rvehundmd dolWn($500). NEW RESIDENTIAL ELLCTR_SOFT.
�n 1,as owner of the properly,or my employees with wages as their sole STORIES TYPE CONSTRUCTION
compensation,will do the work and theetmeture le not intended or offered for
O .1.(Sec.70K Buelcess and Profealom Code:The Contractors License Law
$$ does not apply to an owner of property who Wilda or improves thereon,and
EE who does such work himself or through his own employees,provided that such OCC.GROUIa SM UMTS
–
Improv,meets am not intended orotfered forsale.7f,however,thebuliding or TOTAL: _
Improverrent laseld wthinoneycarofcomple ion,theowner-builderwlll have
thq,kurden of pmvtng that he did not build or improve for purpose of ask.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
U I,as owner of the property,am exclusively moD.–ng with Ilmneed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professiuos Code: [Q
The Contactor.Llcenr Law don not apply to an owner of property who ALTER-DRAIN&VENT•WATER(EN
Wilde or Improves thereon, and who contracts for such plojeaa with a
�'gp([aacres)Bernardi pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJI am exempt under Sec. B k P C for this mason
DRAINS FIOOR,ROOF,AREA,COND. SANITARY Y N I[7
Owner Date RECEII'I'N �I
WORKMAN COMPENSATION DECLARATION
(hereby affirm that I have a mrti0ate of consent to self-Insure,or a FDC URFS PER TRAP SCHOOL TAX Y N
certiBateofWorkens'Comperuation Imu once ma unified copythemof(Sec. RECEP17N
3800,Leb C.) GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE V N
Pollry N GAS EA.SYSTEM-OVER 4(EA) RECEIPT N
Com any BUILDING DIVISION FE ES
�Certifed mpy b hereby thcity inspection division.furnished.
Certified mpy V Tiled withhthe tlty GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF FXEMPFION FROM WORK ERS' GREASETRAP PAID
COMPENSATION INSURANCE SLWF.R.SANTTARV STORM EA.3WFT. �(Do Date Recti tti
(Thtsao.)
1 need mat becompleted lf/be permit Vfor one Fundred dollars
($] mtlrWATER I]EATER W/VENT/E.ECTR ENERGY FEE Y N
mrtify ttishat in the performanceofthe work farwhlch this permit le Issued,
1 shall nm employ an/person In any manner eon to become subject to the WAT R SYSTIM/TREATING
Workers Compem ttloreIowa of C.I fomla. Data PAID
0 Z Applicant NIEW RESIDENTIAL PLMB. SQ.FT. Date Revel t#
Z O NOTICE TO APPLICANT:$ager nuking this CertBlate of Exemption,you
should become subject to the Workers'Compensation provleloos of the Labor TOTAL:
M Cade,you must forthwith comply with such provisions or this permit shall be
W > deemed revoked. UILG FIX
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a coostmctlon lendingagenry for the perform- ELECTRIC FEE
Cr
Z ance of the work for which this permit be Issued(Sec 3097,Civ.C.) TOTAL' I L
U O Lreidera Name PLUMBING FEE ,—(n—C–
LL F Lender.Addres. QTY. MECHANICAL PERMIT FEE MECHANICALFEE
O W Imrti(ythatl love readlhb appEcationaM state thattheabove Nformation
a ummet.I agreeto comply withal]dtyand county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorize representative.of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECIL Date Retial f#
_ (We)agree to save,ledemnlly an d keep harmless the City of Cu pertinc
aga lost llabWtles,judgments,"a and expenses which may In any way statue AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
aga lost said Cityln nary of the grant Ing of this permit.
AIR HANDLING UNIT(OVER 1Q000CEM) CONSTRUCTION TAX
'51gruthem of Applicant/Cortin r Date EXHAUST I IOOD(W/DICT) CONSTRUCTION TAX PA ID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building compact store or hand le harvrdoua HEATING UNIT(TO 100,000 BT11)
material as dofned by the Cupertino Municipal Code,Chapter 9.I3,and the _ Date RBCei IN
health and Safety Cade Sedlon 25533(a)7 HEATING UNIT(OVER 100,000 RTU) TOTAL:
❑ Yrs . MNo �,�a�
Wiiltheapplimot orfmure building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)
which ertJt hazardous air contamdreants a defined by the Bay Area Air � AMCE DATE
Qu alley Management District? BOILER-COMP(31 IPOR 100,000 BTU)
No Yee n❑
`❑n 1 avemad the hazzrdw9 materials mquimrrenls under Chapter 6.95 of BOILER-COME(OVERI 00,000 BTU) jU'vrL
3 U i, i
the California Ilnith h Safety Code,Sediom 25505,75531..d25534.1
NEW RESIDENTIAL MECHpn
understand that ltthebullding docs not mrrcntly haveatenanq that ltbmy . SQ.FT mwAfMJ
responsibility to notify the ocmpant of the mquimmenta which at be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date .R •-Q�
TOTAL: ISSUED BY:
OFFICE COPY