22679 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALL POINT PEN ONLY
BuOding BuildinProeIdeifclon RITNO.Addmn
UO�5 Gi-rn Eh !t d. caper f;.�� C( �� 1 22679
w ere ansa: one:
J�eh2C1j • Z l5i CITY OF CUPERTINO-BUILDING DIVISION
cant, MN'°'°` � Lic'No: APPLICATION / PERMIT
Architect/Regimer. BUILDINGELECTRICAL-PLUMBING-mrcHANICAL CATEGORY CONTROL#
Lie.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. 13C ECECI PLUMB MhLH
❑
LICENSED CONTRACTOR'S DECLARATION
PERMITISSUANCE ❑ ElT hereby affirm that lam licensed under provisions of Chapter9(mmmane APPLIANCESRFSIDEMIAL JOB
Ing with Section 7000)of Dwism.3 ofthe B.Me.exd ProkeslaneCode,and my DESCN
m
licences b In s force and effect. PANELS
LicenCkn • Lt.
'Date Contractor
ARCHITECPS DECLARATION 201-IOOOAMPS -
X I understand my plane shag be used u public rcmnls. OVER 1000 AMT'S SQ.FT.FLOOR AREA $/SQ.Fr.
Licensed Profemkml SIGNS ELECTRICAL
�< 'OWNER-BUILDER DECLARATION SI'FGLILCR(CUIT/#LSC
zo� 1herebyp(Bnnthat lamexempt from the Contractor's Liame Law lmthe -
F2 (oll wingreeson.(Sectlon7031S,Businessland Profesxims Code:Anydtyor
4 cauntywhlch rcqulmapenNttomrutmct,alter lmpmve,tlemolhh,orrepalr TEMP.MEFPRORPOLEINST,
< anyatmmmprimtoib Lssuancgaborequ4 theappuuntfmsuchpermltto POWER DEVICES
U Ble a signed statement that he b licensed pursuant to the provisions of the
3 w
Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- -
�O cion 3 ofthe Business and Pro(eanioN Code)or that he is exempt therefrom and7,ECTR[C .VALUATION
< the bask for the alleged exemption. Any Wolatlon of Sectbn 7Q11.5 by anSWIMMING IDOL I
y
re lFan OUMIITSSWITCHE-FIXTURES
❑ applkant(ora permibubjectathe appaunttoacivll peaity ofnot mo
�� flue undred dollars($500). NEW RESIDENTIAL ELECTR
c owner o!the property,or mmry employers with wages nae mise&eek —SAFE STORIES TYPE CONSTRUCTION
m pensatlon,willdothe suns&,andtheatwdurobnm Intendedaro((ered for
❑ ea 70dd,Buekeu and Pro(emlons Cade:The Contnctole Liceme Law
dma not apply to an owner of property who bulide or Improve Thereon,and
000... whodceeauchworkhimselforthrough hieownemployees,provided that such OCC.GROUP RIES.UMTS
ImprovemenU are not Intended oraf(ered foreale.IL however
hisser TOTAL:
Improvement kwld withinomyearo(complNion,lheowner-builderwW have
t)(�kurden ofpmving that he did nm build use Improve far purpose ofeels.). QTy, PLUMBING PERMIT FEE ,
�f L as owner of the property,am excluelvely rontracting with licensed bL00D OZONE APN
mniraciors to mnsWct tics Project(Sec 7041,Buelnem and Proleolons Code: PERMIT ISSUANCE lyzi
The Canersctars Liana law dose not apply m an owner of property who
builds or Improve thereon, and who of (or such pwJects with a ALTEB-DRA1N&VENT-WATER(EA)
co,,11VV(Ttra
actor(s)licensed pursuant to the Conctors Liana Law. FEE SUMMARY
LI I am exempt under Se, R&P C for this reason BACK FLOW PROTECT.DEVICE
Owner - Dace OUTSIDE FFFS
DRAINS.FLOOR ROOF,AREA,COND. - SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIPT#
0 hereby affirm that 1 have a certificate of consent to ail-Iowa,or a FD(Tl1RES PER TRAP SCHOOL TAX Y N
cenificateofWork m''Campensatlonlmumnce ora certfted copythemof(sec. RECEIPT
3800,[ab CJ GAS EA,SYSTEM-1 INCAOUTLETS � 1 PARKFEE Y N_
Policy 0 RECIDPT#
Com any GAS EA.SYSTEM-OVER4(EA)
ffCenlfied copy b hereby furniBUILDING DIVISION FEES
shed. -
E3 Certified copy is filed with the city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(TM1IssMion need oat be completed lithe permit k(orom hundred dollars SEWER-SANITARY-STORM EA.Man Date Re i t#
($100)or..)
Icertify that&the Performance of the work for which this permit is Issued, WATER HEATER W/VENT/EI--FGTR - 'ENERGY FEE Y_ N_
I shall nm employ any person In any manner so Me to become subject to the '
O
Workets'Cempensatlon Laws of California.Date WATER 5YSIEM/TREATING .PAID -
Z 'Applicant
2 0 NOTICE TOAPPLICANT:If,afier making thCcCcllfom of a.mpien,you NEW RESIDENTIAL PLMB._SQFT. Date Re i t#
L)
should become subject to the Workers'Compemxtlon provisions olthe Labor TOTAL:
Code,you must forthwith comply with such provisions orthk permit shall be
W > deemed revoked. B 'D ,
IL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby aorktor tthvobemmtmctlon lendingagency 7,Ci,. .) perform- TOTA ; ` ELECTRIC FEE
D Z once of theworklorwhkhthh permit it Issued(See 3097,C1v.C.) �
U O Lcriderb Name PLUMBINGFEE
LL 0 LenderlAddress QTY. MECHANICAL PERMIT FEE 7 lam
MECHANICAL FEE
O W Iartltythatlhave read thhappgmtionarW statethatthealmm Informatlon
CL lemmod.l agrmto complywith all city and muntyotdkances rad state lawn PERMIT ISSUANCE FEE -
PAID--N relating to building mnstac5ogand hemebyauthalu representatives ofthk
Z city toenter upon the above-mentioned property for Inspection purpose, ALTER OR ADD 70 MECH.
— (We)agree to save,Indemnify an d keep harmtea the City of Cope"too Date Receipt#
against liabilities,judgmental cops and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) - SUBTOTAL•
a t said Ci in conseque of the granting of this permit.
' AIR HA LADLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature.!Ap Icmt/Codtrmtor ate EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wlllthe applicant orfumrebuilding occupant store or handle haraidous HEATING UNIT 00 I(Doso BM
material as defined by the Cupertino Me nldpal Code,Chapter 9.17,and the Date Recei t#
Ilealth and Safety Cade Section25532(a)? HEATING UNIT(OVER 100,0110 BTU) TOTAL.
Yee No
Will the appllmnt Be tum bulldingoccvpantumequipmenturdevim VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
ality Management District?. - BOILER-COMP QHPOR 100,000 BTM )
Y. n❑No
materials
read the its ous materia&
CEJ, requirements under Chapter 6,95 of BOILER-COMP(OVER 100,000 BTU) �®
the California Health&Safety Code,Secim to25505,25533 and 25534.1 '
understand shat if the bulldNg docs not mrrently haveatenanr that ilkmy NEW RESIDENTIAL MECH. �.FT
responsibility to notify the occupant of the mqulmments which moat be met �
Prior to issuance of a Certificate of Occupa ory. 1[CP 19911&
Owner or authorized agent Date ISSIIEDBY:� �Y —
TOTAL:
OFFICE COPY