22117 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proest Identification PERMIT NO.
baildiogAddonw
d9 r•-N 2 2 1 1 7
A
nn CITY OF CUPERTINO-BUILDING DIVISION
G to ° s are: LIe.N°: APPLICATION / PERMIT l�
va'aT BUILDING-ELECTRICALPLUMBING-MECHAMEG
CAL CATEGORY CONTROL a
Architect/Ggine Lle No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑ I�
LICENSED CONTRACTOR'S DECLARATION �V
I hereby affirm that l am Lessued under provisions of Chapter 9(mmmen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Section 7000)of Division 3 ofthe Busi news and PrefenionsCode,and my
license is In f effect. PANELS
Lice sec ICN A ` �+�•N
Dal Contractor I 1UP TO 200 AMM -
ARCHITECT'S DECLARAT N 701-1000 AMPS
rt Zp I understand my plans shall be used as public records. OVU1000AMPS FI'D RSR $/SQ.Ff.
I2Fial ly Fj Licensed ProfessionalSIGNSELFGTRICAL I
6
OWNER-BOLDER DECLARATION SPECIAL CIRCUIT/MLSC p U �'E R
Ihercbyaf0nn tOWI am exempt NER-BOLD RDE DECLARATION
Gw(or the
following reason.(Section 70315,Business and Professions Code:Any city or
O p. TEMP.METER OR POLE[NST. qqq
�� cy oounlycwrx requlresa permne,wnrequirestheapmvgdemoRah,ormpaironitto �Q d?
7a any assigned statement
that
he is aleore d pursuant 1.the fonuch s;of t e POWER DEVICES fV 0
r� V IIIc a signed statement thN he t&licensed pursuant to the provisions;of theONSWUNSMGWAMIWMMOW
Ory Contractor's License Law(Chapter 9(mmmeneingwith Section 7000)ofDivi.
�OJ Nona ofthe Business and ProfenloneCade)orthat he laexemm
pt therefmand SWIMMING IDOL dECITUC VALUATION
the bast&for the alleged exemption. Any violation of Section 70111.5 by any OUILE•L&SNR.CC}IESF7%•LURES
applicant for a permit subje tsthe appgcant to a civil penalty of not marethan
five hundred dollars(5500). WE ESIDENTIAL ELECTR
�n ❑I,as owner of the property,or my employe.with wages as their sole —SQFT• STORIES TYPE CONSIRUCTION
CCcompensation,will do the work and the atmcture Is not Intended or offered for
q sale(Sec 7060,Bushes.and Professlo.Code:The Contractors License Law
$ don not apply toanowner of property who builds or lmprovea themeRand OCC.CROUP RES.UNITS
who doessuch work himselforlhrwgh his own employe.,provided that such
Improvements are not Intended or offered for sale.If,howevep the building or TOTAL:
Improvement Is sold within ooeyearofcompletlory the owner-bullderwlll have
the burden of proving that he did net bu lld or improve for purpose of sale.). QTY. PLUMBING PERMIT FEEFIADDZONE APN
L ;as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7066,Business and Professions,Code:
The Contractor's License Iaw does not apply to an owner of property who ALTER-DRAIN k VENT•WATER(EA)
builds or Improves lhereory contracts and who contfor such p( m ojewith a
oJoEiactor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
OUTSIDE FEES
DRAINS.FLOOR,ROOF,ARRA,COND. SANITARY V N
Owner Date RECEIPT If
�../' WORKMAN COMP ENSATIONDIc ARATION FIXTURES.PER TRA[' SCI100L TAX Y N
MRI hereby afflmm that I have a certificate of consent m se141nsure,ora R�EI'C I
38031�bexeofWorkrs CompewTal^lonlrwurance or.certified copylIs— Sec. GAS-EA.SYSTEM•[INCA OUTLETS PARK FEE Y N
Policy M V..111�1 1("1 /oV RECEIPT 0
Com s GAS G.SVSTFMAVER 4(EAJ
� Y C 11 '� BUILDING DIVISION FEES
`}}}rtified ropy t&hied wi, rthe CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
copy la filed with the ctty inspection
division.
CERTIFICATE OF MEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SMITTARYSIORMEA700E-T Date Remi 1#
(lhbuctlon need not he completed tithe permit litforor�e hundred dollen
($100)orless.) WATER HEATER W/VENT/ELFlTR ENERGY FEE Y N
I certify that In the performance ofthe work forwhlch this permit is blued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compens.11on Laws of California.Dale PAID
O Z Applicant
Z G NOTICETO APPLICANT.I;afler making this Certificate of Exemption,you NEW RE4DENTIAL PLMB._SQFr. Dale Remi 1#
Hshould become subject to the Workers'Compensation provisions ofthe Labor - TOTAL:
WN Code,you must forthwith comply with such provisions orthla permit shall be BUILDING FEE
�f deemed revoked.
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform, ELECTRIC FEE
7 Z anceof the work for which this permit is Issued(Sec.3097,Civ,C.) TOTAL:
U O Lender.N.me PLUMBING FEE
LLH Lender.Addre. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 111 Icertify that]have read tht&appBmtion and Natethat the shove infommtlon
t&mrrect.Iagre,tocomplywlth all cityand countyordinance andmlaws PERMIT ISSUANCE FEES PAID:
} a relating lobulldingwratrudion,and hereby authotl.representatives oflht&
I" N city toenterupon the above-mentioned property for lvpectlon purposes, ALTERORADDTOMECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,coinsand expenses which may in anywayaccrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
d
By In consequence of the gra rating of this permit.
AIR HANDLING UNIT(OVER 10,000 CIM) CONSTRUCTION TAX
Si a not AppU.nt/Contractor - Dale EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willthe applicant orfuturebullduRocmpant store or handle harardous 7
HEATING UNIT(TO IOD,(pO gTU)
mNeriaias defined by the Cupertino Municipal Cods,Chapter 9.12,and the Date Revel t#
I ealth and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL: c
F1 Yes M No
Willthea pplieantorfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent haaardoua air contaminants as defined by the Bay Area Air
u�Illy Management District? BOILER-CDM?(31 IF OR 100,000 BTU)
44Y.havered
e`ie Iced
havereazy casesd the hmaterials requirements under Chapter 6.95 of BORER-OOMP(OVER 100,000 BTU)
the Calif°rnla Flc.lthkSafety Code,Sedio.25505,25533and25536. I
NEW RESIDENTIAL MECH. SQ.ET JUN 2 01991
understand that](the huliding docs not corrently have atenan;that itt&my
resporulbllity to not lfy the occupant of the requirement.which must be met pt
prior to issuance of.Certificate of O=p.ncy. W
NJ yyrp0►liAn
Owner or aulhorired agent Data ISSUEDBY.
TOTAL:
OFFICE COPY