22741 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
Building Project Identification - PERMIT NO.
Building Address:
22741 ,
i
: AL WAIL
sum one
a arta CITY OF CUPERTINO:BUILDING DIVISION (] /
Cnntraet - N LteNm APPLICATION / PERMIT
CATEGORY RY CONTROL N'
BUILDING-FIFATRICALPLUMBINC-MECHANICAL
Amhued/Engineer. Lm.No: BUILDING PERMIT INFO - -
QTY .ELECTRICPERMIT FEE'
Address PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm that l am licensed under provisions of Chapter9(mmmenc APPLIANCESSRESIDENTIAL JOB DESCRIPTION
Ingwilh S&ct1on7000)of Dlvisim3 ofthegusinessand ProfessionsCode,and my -
Ilanae is in(u8 force and effect. G n - PANELS .
License Clem s- Lt.
Oak orm- Comer ct �-
ARCHITECTS DECLARATION OVER0O AMPS
ODOAM
pppppp QZgO Iunderstand my plans shall be used upubllcremrde. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FC.
�z(� Licensed Profeaional SIGNSELECTRICAL n e ED I
6 m OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC- _1 tA`�•
zE,iiA? - Ihereb'yaNrmthatlamexemptfromthe Contrador.Llrenx Lawforthe -
oo H following recon.(Section 7031.5,Business and I§ufinebns Code:Any dty or v a � T E R
O Z'" TEMP.MET[ItOR POLE[NST.
P p countywhlch rcqulresa pemdttomrutrud,alter,impmve,demolish,orrepalr
q0 anystructure priorto its Issuance,also requlreithe app1mritfor such permit to OWER DEVICES
t�LWWG�55 file a signed statement that he Is licensed pursuant to the provisions of the
�u, Contradoes Licmme Law(Chapter 9(mmmendng with Section 7000)of Dlvl- SWA4MINC POOL ELECTRIC
0 simn3oftheBusN sandProfemloroCode)orthathelsewmpttherefmmand ON
O the basis for the alleged exemption. Any violation of Section 7MI5 by any OUTLEISSWITCHESFIXT'URES
aPph..t fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars($5M. NEW RESIDENTIAL ELECTR
❑I,as owner of the property,or my employees with wages as their sole SQ.FL STORIES TYPE CONSTRUCTION
compensation,will do the work,and the structure b not intended or offered for
Dsale(Sec.7044,Business and Profeaslom Code:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
0.0. who doessuchwork hlmselforthrasgh hkownemployess,providecithat such ,
imprower:mus are not Intended oroffered for sale,If,however,the building or TOTAL: -
improvereentlssoldwilhlnmmyearofcompletlon,the owner-bullderwlil have -
the burden of proving that he did not build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licemtd
ountractors to construct the projed(Sec.7044,Business and Professiom Code: PERMIT ISSUANCE _ -
The Contractors Lkeme Law does not apply to an owner of property who
builds or Improves thereon, and who contracts for such pla)ecb with a ALTER-DRAIN&VENT-WATER(EA) - -
or�npt(Frador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
01 am exempt under Sec B&P C for this reason — OUTSIDE FEES
BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date RFOI]PCX
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have o mint ra c of consent to opy themo ora RECEIPT X
certificate of Workers'CmmpensationInsurance ars adi(kd mpythemof(sec. GAS EA.SYSTEM-1 INCAOUTLEIS PARK FEE Y N
3800, ab
PoI1gX -7' GAS EA.SYETFM-OVER4(EA) Dp
Cam any - BUILDING NG DIVISION FE ES
L��L��ppCified copy is hereby tth ed. CREASE/INDUSIRL WASTE INTERCEPTOR - PLANCHECK FEE
Codified ropyisfiled with the city inspection division. � _ .
�aaaPPPP CERTIFICATE OF EXEMPTION FROM WOSKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAMTARy-STORM EA.IOOFf. DOIC Remi t#
(This aedlon need not be complded If the pertNt b forone hundred dollars
($100)ur less.) - WATER I IFATER W/VENT/ELMTR ENERGY FEE Y_ N_
I certifythatin the performance ofthe work forwhich this permit Is Issued, If I
I shall not employ any person le any manner w m to become subjed to the WATER SYSTEM/TREATTNG PAID
Workers'Compensatlon Laws of Califomb.Date
0 Z Applicant NEW RESIDENTIAL PLMB.' SQ.F'I. Date Recei t#
Z NOTICE TO APPLICANMlf,after making this Codifiam of Exemption,you
should become subject to the Workers'Compensatlon provisions ofthe Labor 'TOTAL:
N Code,you moat forthwith comply with such provisions orthb permit shall be . U
LU j - damned revoked.
ILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
'IL I hereby affirm that there b a construction lending agency for the perform- ELECTRIC FEE
:3Z ane&mfthe work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL: r
en
V O Lder.Nance PLUMBING FEE
LL h- Lander.Address - QTY. MECHANICAL PERMIT FEE
SII-O W cerre
'Itllythatl have ad thbappliagak
tumand thatthe above Information MECHANICAL FEE
1 Lscorrect.I agreeto comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. W relating to building camtrudlon,and hereby authodz&representatives of this -
(— city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
? . (We)agree m save,Indemnify an d keep harmless the City of Cupertino Date Recei t#
V
against liabilities,judgments,was and expenses which may In anywayaccme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
Lit said City in conseq nae of granting of this pemdt.
i�q �e� AIR HA NDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
nature of Applicant nrdor .Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAlA RDOUS MATERIALS DISCLOSURE
Will the applicant orfuhm,building occupant store or hand le hazardous HEATING UNIT(TO 100,000 BTU) Date Recei of#,
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BED) TOTAL:
❑Yea rQ No - ..
Will the applicant ord t m building ottvpantuwequipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which moll hazardous air contaminants as defined bylhe Bay Area Air
g - Quality Management District? -- - BOILER-COMP OMPOR 1310,000 BTU)
ii �I Yes �No �� - '
`(have read the haz us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 4Iy
p _., a the Call orela Health&Safety Code,Sections 25505,25533 and 25534.1 -QEC ^' 1991
understandthat if the building does not currently have atenanq that It NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant ofthe requirements which must be cart -
riorWesumceo(aCc Ifica of Occupancy. ,CITY �1r jp�tj I Illu
VQ i '–
Owner orauthorze agent - Date TOTAL: ISSUEDBY: I
OFFICE COPY