22853APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project Identification
liullding Address:
PERMITNO.
a ,e
22853_
arae: one:
ner. •C.
CITY OF CUPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BULDINGQ ECTR CALP UMBINC-MECHAMCAL
p
10-10-11 J ���i'i I
—` 0 1
tans:° me: ua. Na:
S r LTx� G o-io aaa I
CATEGORY
CONTROL R
Arc Iter/Engineer. Lle, No:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address:
F7 A71 [:] ❑
PERMITISSUANCE / -(�
LICENSED CONTRACTOR'S DECLARATION
I hereby af.70Mthat lamllcenaefth.Buinemaprovinces uteadonsCode annen
It...I Infall force of DIWect. tthe Busineuand Pro(eulonaCode,and my
license le In fug force and
APPLIANCESRFSIDENTIAL
JOg DESCRIPTION
{
PANELSLi
Cls® Lica
a, #
� I
�
Date
Date Contractor
— UP TO 200AMPS
lr V I
�
201-1000 AMPS
ARCHITECTS DECLARATION
I understand my plans shall be used as public records.
as
OVERIMOAMP91T.
F -A
5/SQ. FT.
SIGNS ELECTRICAL
Licensed Professional
�.a
SPECIAL CIRCUIT/MISC
OWNER -BUILDER DECLARATION
I hereby affirm exempt xemptfromthe Contractor's se Law the
fallowing reason.(Sectlon 7031 S, Business and Professions Code: Any city or
county which regWm a permit to construct, alter, Improve, demolish, or repair
1 ER
M / �/ c
Q
'
TEMP, METER OR POLE INST. TE
any simcture priorto its luuance,alsorequireslheappRunt forsuch permit to
file a signed statement that he is licensed pursuant to the provisions of the
Contractors License Law (Chapter9(commenctngwlth Section 7000)of Divi.
don3 of the Budemand Professimu Code) orthat he b exempt therefromand
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
the basic for the alleged exemption. Any violation of Setllan 7031.5 by any
applicantlora permit subjects the applicant to a civil penalty of not m mlz
OUTLETSSWITCHRSFIXTURFS
14
O ve hundred dollars ($500).
❑ L as owner of the pmperty, or my employeeswith wages as their sok
NEW READENTIAL ELECTR —7.-7'
STORIES
TYPE CONSTRUCTION
compensation, will d o the work and the structure is not Intended or offered for
ale (Sec. 70K Business and Professions Code: The Contractors License law
does not a pply to an owner of property who builds or improves tMnon,and
who doessuch work himselforthrough his own employees, provided that such
OCC, GROUT'
RES,
Improvements arc not intended oraffered forsale. If, however thebuilding or
TOTAL:
Improvement b sold within ane yearofcompletion the owner-budderwill have
tr rden ofpmving that he did not build or Improve for purpose dfule.).
Ilrenaed
Lj 4 or owner the property, am exclusively Business
a to construct the project (Seer Business and
nd Professions Code:
undox,toThe
QTY. PLUMBING PERMIT FEE
FLOOD ZONE
APN
PERMIT ISSUANCE
ont of prolant
Contractor'sLicense
The Coor Impter Lirense Law dad not apply tct an owner of property who
apply
Wilds or Improves thereon, and e o contracts doe. for each projea[s with e
off,or(sexempe under Sec to the Contntlors License Law.
U I am exempt under Sec. B & P C for ebb recon
ALTER -DRAW VENT- WATER 0?N
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS. FLOOR, ROOF, ARRA, CONTI,
F'IX'NRpS PER TRAP
SANITARY Y N
RFGEBT M
Owner Date
WORKMAN COMPENSATION DECLARATION
❑I hereby aRUm that I have a certificate of consent to self -insure, or a
certificate ofWmI m` Compensalionlnsurance wa certified copy themof(Sec.
3800, lab C,)
SCHOOL TAX Y N
RFGEIPT N
CAS G.SYSTFAT•1 INCA OUTLETS
PARK r Y N
Com a
RECEIPT
GAS EA. SYSTEM -OVER 6(EA)
Com any
BUILDING
BUILDING DI VISION FF. ES
copy b hereby filed
®Certified copy b filed with the sty Inspection division,
the cityI
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCI IECK FEE
'
GREASETRAP
• CERTIFICATE OF MEMPTION MOM WORKERS'
PAID
SEWER -SANITARY -STORM EA. 200171.
COMPENSATION INSURANCE
(Thisoection need na be completed RtM1e permit ts fou ossa hundred dollars
(StOo)oify that
.norwork so
Illnet thatlntheperrson I. a to which this
I shall not employ any persue In any rnsnner at ae to become subject to the
suittsbo the
Workers 'Compensation Laws of California.ATER
la. Date
Date Recel t#
WATER HEATER W/VENT/ELECTR
ENERGYFEE Y N
PAID
SYSTEM/TREATING
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you
should become subject to the Workeri Compensation provisions of the Labor
Dale Recel t#
NEWRESIDENTIALPLMll. SOFT.
TOTAL:
Code, you must forthwith comply with such provisions orthb permit shall be
deemed revoked.
BUILDING FEE
SEISMIC FEE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the perform-
ance of the work for which thin permit tat issued (Sec. 3097, Civ. G
TOTAL:
ELECTRICFEE
a
Landers Name
Lenders Address
I certify that I have read this application and state that the above tnfomvtion
Is correct.I agree to comply with all city and county ordinances and nate laws
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
relating to building construction, and hereby authorize rep nstodatives of thin
city to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnlfy an d kaep harodew the City of Cu pen loo
against IJ.hlJ jrdgmente,crata and expenses wh lch may In any way. acerm
abut cal In ens olthe granting o(thb permit
�0
Signature of Appllcant/Contractorto
ALTMORADDTOMECH.
Date Receipt#
AIR IIA NDLTNG UNIT (TO 10,000 CIM)
SUBTOTAL:
AIR HANDLING UNIT(OVER 10,000 CITU
CONSTRUCTION TAX
FXI IAUST HOOD (W/DUC'p
CONSTRUCTION TAX PAID:
HAZA R DOES MATER IALS DISCLOS RE
HEATING UNIT (TO 100,000 BTU)
-
Will the a ppllnrat or fund to building occupant store or handlebarardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 2, and the
Iic❑alt Yaannd Safety Cod�olon 25532(a)7
Date Recelt#
HEATING UNIT (OVER 100,000 BTU
- TOTAL:
1
VENTILATION FAN (SINGLE RESID)
ISSUANCE DATE
P -MM
Will the applicant or future building occupant use Nuipment or devices
which emit havrdous air contaminants as defined by the Bay Area Air
( u�ality Management DIs)fict7
BOILER -COMP (31IP OR 100,0() BTU
Yes�,a]j No
BOILER-COhip(OVER 100,000 BTU)
haveread the haze ousovtenab requirements under Chapter (05 of
the California Healthk SafetyCode, Seetiou25505, 255533 and 25S36.I
OCT^'1
3
NEWRISIDENTIALMECH. SQ.IT.
understand that if the building does not currently have a tenant, that It is my
responsibility to notify a eacdpanl of the requirements which most be met
prior uance mficat doccupanry.
CW of Cuper�rt�
ld fa
�.I �.
ISSUED BY: -I` �C
caror authwtred agent Date
TOTAL:
OFFICE COPY