22678 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - P]RMBTNO.
Oudding'Addrust: voL.C1 K4,8uS c 22678
s n' APPLICA7T0V7I79RITrAT=
ter pt,lA-6 E7 �p,Szj CITY OF CUPERTINO�BUILDING DIVISION
CanaIr LI=Na APPLICATION I PERMIT
BUILDING-ELECTRICALPLUMBINGM/FLHAMCAL CATEGORY CONTROL
Architect/Engineer.
Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUA.NCE lal� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L71
Ihth Seaon7Othat I am)ofDivsi=3ofed underpenandmfenionsCocommon APPLiANCESRESIDFMTAL JOB DESCRIPTION
inenseISection force it died. PANELS my J - -�S '
license la In s (arm and c.# PANELS
LicenseClaes LION
Date Ccorrector UP TO 200 ANTS L
ARCHITECPS DECLARATION 201-1000 AMPS
q�q�uu p O I understand my pons shall W used u public records. OVER 1000 r I I R AREA $/SQ.FT.
k 2kd Licensed Profimal SIGNS essELECTRICAL _ r
OWNER-BUILDER DECLARATION I 1 -
I'n SPFCIALCRCUI7/ L
o ('. f l I I lv
p, ]hereby a(flrm that lam exempt from lhe Cantractor'•Llcenu Law for the M _
�.. following reason.(Section 7031.5,Business and Professions Cade:Any city or T P.MEHR OR POL NST. N�,a
county which requires permit lnmnstroM slurs Improve,demolish,or repair
qany structure prior to its issuance,also mquirssthe applicant foriuchpermit to POWER DEVICES DATE
E°0 F ilk a signed statement the he It licensed pursuant to the provisions of the
3w Conlrs cemeawl pler
anor' Lll (C9h&tt1on70ofDwi-
110)
OI-n (commentl ,g lSWIPIMING POOL ECCRIC
eon3 of the Bu
ualneand Pro(enbns Code)orthat hell erempttherefromand VALUATION
the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXTURES O`
SEGW75J applicant fora permit subjects Nm e applicant to a civil penalty of nmore H /nun ` )
five rifted dollars($500). SQ.FT. STORIES TYPE CONSTRUCTION
as owner of the property,or my employe"with wag"as their sole 'NESV RESIDENTIAL ELECTR
penuHon,wlll doted work and lheemcturelsnm Intended or offered for
Ou e(Sec 7054,Business and Professions Code:The Contradoe.License law
does not apply to an owner of property who builds or Improves thereon,and OCC.GROIIIs RES.UNITS
dace such work himself m through his own employees,provided that such
Improvements arc not intended oroffered(mule.If,howerver,thebuildh g or TOTAL;
Improvement lssold within oneyearof completion,the owner-builderwill have
tkiLtlirdenof proving that he did rout build orlmprove for purpaaeafule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
Lj L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business and Prof"slots Code:
The Contnctm's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(FN
Wilds or improves thereon,and who contracts fm such plo -
jacts with a FEE SUMMARY
mp(Laaorts)Bmnrd P-owu l to the Comrades.License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under gen B&P C for this rescan
OUTSIDE FELS
Owner Data
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RECEPT p
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
❑I hereby affirm the I have o lmu mte of consent to Dpythe r f or a RECEIPT N
certi0mteofWorken'CompensaHonlnsurancema certlfkd copythereof(Sec.
3800,lab C) GAS EA.SYSTEM-1 INCAOUILETS PARK FEE Y N
Policy N GAS PA.SYSTEMAVER 4(FA) RECEIPT N
Com ny BUILDING DIVISION FEES
Certified copy In herebyth the city CRFASHANDUSfRL WASTE INTERCEPTOR PLANC14ECK FEE
Certified copy ls filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' CREAM TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 100Ff Date RCCeI t#
(Thlssecti m.ccd not hem epluted if the permit b furans hundred dollars
(g1 m)ca,to..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify,that In the performance of thework forwhich this permit Is issued,
I shall not employ any person in any runner so as to become abject to the WATER SYSTEM/TREATING
Workers'Compenutlon Lam of Callfomla.Date PAID
z z Applicant NEW RESIDENTIAL PLMB. SQJrT, Date Recei t#
Z O NOTICETOAPPLICANT:If,after makingthls Certillcateof Exception,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions orthls permit shall be BUILDINGl
W > deemed revoked.
a F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby af0rm
that there Is a construction lending agency for the perform ELECTRIC FEE
O an.of the work for which this permit is Issued(Sec.3071,Civ.C.) TOTAL:
V Lurdere Nesse PLUMBING FEE
LL F Le.dee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W bmm
I.Aifythatlhavereadthlsapplir tl nandoalelhattheaboveinformation
a rtcct.I:gree to comply wlthall city and untyordbutecsand Nate laws PFRMTTISSUANCE FEES PAID:
>. relating to building construction,and hereby authorise representatives of this
f" Z city to enter upon the ahow,menlloned property for Inspection pu rposes. ALTERORADDTOMECH.
— (We)agree to save,Indemnify an it keep harmless the City of Cupertino Date Reeel t#
agalnstllabNtl ' dgmenta,me sand expect w kh may In anywayaceue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.galea alit mnsrryence ft gotlhZoi l petmlt.
3 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Igul of pp cant/Conlr nor 10.4 EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumv building oavpart store or handle haeardou. HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as dellned by the Cupertino Municipal Cade,Chapter 9.1 2,and the
I fralth and Safety Code Section 255311217 HEATING UNIT(OVER I W,000 BTU) TOTAL:
1 l Yes No
Ill theapplicaut m hare Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCJW
which emit hararlous air contaminants as defined by the Bay Area Air R`
Qu Illy Management District? BOILER-COMP(3HPOR 100,000 BTU) ��kEC
(� 4 Yes Q No 3 1
haveread Health
oet materIsis nqulrerrc5,25S3under nd 25534.1 of BOD.ER-COMP(OVER 100,000 BTU) �kY Q91
lhsundertandt Health&Safety Code,Sectionsntly have
a and 75534.! !NY
responsibility
that notiff they
building does not the
which
thatb mot NEW RESIDFNIIAL MECH. SQFI'.
rvor to Issuance
ce of aCtheoccupantof ccupa rtqulremenla which musl6e sued fV1yK
prior to luuance ofa Certificate of Occupancy. ��/�aly��1�[ a7
Owner or authoHud agent Date ISSUED BY: � n__r(
TOTAL:
OFFICE COPY