22738 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project ldemlflatlon PERMITNO.
Blt9oz w(po 3o �� . . 22738
Ls4ame: one:
��gv ru (CES i CITY OF CUPERTINO-BUILDING DIVISION �7 L
tentractor's APPLICATION /PERMIT
s VC.t-� �7CJf'a'rL -�' t ICNAfwJ S BUILDING¢ECTWCALPLUMBING-MFGHANICAL CATEGORY CONTROLJI
Architect/Englneer. Lie.No:
P. l2 C.OIA.t.f+ BUILDING PERMIT INFO
QTY ELECTRIC PERMIT FEE
Add.-
LICENSED
❑ ❑ (� ❑
LICENSED CONTRACTORS DECLARATION L�f
' Ihereby
ion7OOhmlamhcensefthe Bu nessannsof Chapter
ssions9de,and APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwJtlimnseh Section force of DlNmon3o(thc Bumndaeand Pro(esslonafbde,and my
license Is in run loses and erred PANELS `
LicenseClass Licp
Dale __Contractor UP IQ 200 ANIPS
ARCHITECTS DECLARATION X11.1000 MPS
q�q�uu
asC I understand my plans shah be used as public records. OVER 1000 AMPS - SQ.Fr.FLOOR AREA $/SQ.Fr.
Ob
Fi z U Licensed Professional SICNSELFJCTWCAL
IN
G< g OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC L�
7
'4 1 hereby affirm that l am exempt from the Contractor's License Law for the -
oo (ollawingreason.6cctlon70i15,Buslnessandl'rolessbnsCode:Anycttyor I i� �? 5
O 2 i- TEMP.META(ORPOLE INST.F� ES
anystmcourtyumprihich ultnapmance,alsoermit quimtheauct,alter, pmvgdemo)hh,er ttr
qq'' any structure tatemelts that
he Is
Bene d pursuant t the provisions
of t e POWER DEVICES Z
6'� � file a signed statement that he V BcensN pursuant to the provlaloru of the w�
R3f3 Contractors License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC Mss VALllAT ON
�O aon3 of the Business and ProfesdaruCode)orthat he is exempt therefromand
ST) the basis for the alleged exemption. Any violation of Section 70712 by any OUILETSSWITCHESFIXTURFS
applicant for a permit subjects the applicant to a civil penalty of not more than
five hundred dollars(4500).
NEW RESIDENTIAL ELECTRSQ.Fr,
�n ❑I,as owner olthe the work,. or my employees Is mwith inters ed r offered
sale fo STORIES TETE CONSTRUCTION
compeneatlon,wllldo(heovork and thestmclure la not Intended or offered for
does q sale(See appy to alnow and f property
Codb:The C Improves
Mrerue law
jrj3$ and
whodot apply torn owner offprough his onemporimprorroryuch OCC.GROUP RFS.UNITS
MM whodoeLetsach not Intededolf rough hleowae.If,ho es,providedthebuihatwch
Improvementsareno[Intended earofco forsek.tr,however, deer ilt have TOTAL:
improvement is sold within one year°lcomplellorytheowner-bulldcrwlll have
tfyn-litrden of proving that he did not build or Improve for purpose ofsakJ. QTY, PLUMBING PERMIT FEE FLOODZONE APN
U L an owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to mtvtruct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAM&VENT-WATER(EA)
Wt or Improves thereon, and who contracts for such ppajeds with a
,6ractor(s)licensed pun uarec.uto the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L)I am exempt under SB&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• OUTSIDE FEES
Owner Dale RECEIPT_ Np
WORKMAN COMPENSATION DECLARATION FnCILRF.S PER TRAP 100E TAX Y_ N
❑1 hereby affirm that 1 have•certiBa c of consent to op(thereof
ora RECEIPT M
certif3800,iab C(Workers'Compensatlon Insurance aracertlfled ropy therm((Sec. GAS.EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
38W,lab C.)
Policy M RF-CER'T p
CAS EA,SYSTEM-OVER4(EA) BUILDING DIVISION FE ES
Com any
Certified copy is hereby te
❑Certified copy la filed withh the city
Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE
ity
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA XXIFf Date RCYCI I#
(ThlsseNon need not be completed If the permit Is(°rand hundred dollars
(4100)m Icas) WATER HEATER W/VENT/¢IeCTR ENERGY FEE Y N
I mrtlfythat in the performance of the weak forwhlch this permit is is nood,
I shall not employ any person In any manner se as to become subject to the WATER SYSTEM/7REATINXO
Workere'Compenution laws of Callfomla.Date PAID
O Z ApplicaNOTICE NEW RESIDENTIAL PLMB._SQFT. Dale Rece) t#
Z p NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions°(rise Labor TOTAL:
N Code,you at forthwith comply with such provisions or this permit shall be
j deemed rovoked. D G FEE
CLCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby afRrro that there b a corutructton ladi
nng agency for the perform ECTRIC FEE
Z anceofthe work W,viuchthis permit is heated(Sec.3097,CIv.C.) TOTAL:
U O Lender.Name LUMBING FEE
LL Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Iaklfythailhavereadthis appllatlon and stat hat the above information
1 lacorrect.ILgreemcam lit with all elyand ty ordinances and mate laws PERMTI ISSUANCE FEES PAID:
N relming Winaildbg m'I.n,and hereby thorize representatives of this
Z city to enter upon) above-=tkx x[p arty for inspection purposes. ALTER OR ADD70 MECH.
(We)agree t M...'
and a armless the Clty of Cupertino Date Re e1Pt#
V against Ila Ills aa x seawhich nvy banywayaccme AIR HANDLING UNIT(TO 10,ODO CFM) SUBTOTAL:
agal�t Ity In re sting of this permit.q ��_4LAIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Signature of Appll Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will therppllcaet or future Wildingomupantstmem handle hazardous HEATING UNIT(M 100,000 BTU)
material as deflmd by the Cupertino Municipal Code,Chapter 9.IZ and the _ Date Recel l#
Health and Safety Cade Section 25532(a)2 HEATING UNIT(OVER 100,00)BTU) TOTAL
❑ Yea No
Will the appliantea wmbultdinga pantumequipmentwdevicm VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit havrdous air contaminantsas de0ned bythe Bay Area At, - Aatd�ss
Quality Management District? BORts
ER-COMP p 'OR 100,000 BTU) R"AI'D
4 Yo �I No
have read the haza ousmmerlals requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the Ca)ifornla Health&Safety Code,Sections 25505,25533 and 25534.1 SEPI '7
understand that if the building docs not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQJr �/II
resporo LbuA toofacenifi occupant of pancyulremenb which moat be met /llh.1Pj�
resortsissuance notify
iythe ccu .Occupy he exq (��''1 /s�
qtzz
Owner or authorized agent Date ISSUED Y.-
L
TOTAL:
OFFICE COPY