22143 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification PERMITNO.
BuOding Address: 22143
wm�s a10me: S A
B 1 CITY OF CUPERTINO-BUILDING DIVISION C?//
Contra Lk.No: gppLICATION /PERMIT ^-a ` /
BUfLDING-F2.FLTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL M
Architect/Erngineer. Ic No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addttsa: PERMITISSUANCE .Q d 1:1 19 El El
CONTRACTOR'S DECLARATION
IhthSMion7Othat fDiviM=3ofheBusiremannrotfemionr9de,and c AIRLIANCESRE9DENffAL JOB DESCRB''DON
IngwlthSatellf.enandvWct, 'heBuslnessandProtesslomCode,and my
Iimnae le In fun force end dint, PANELS
License Class Lie.0 5MS! 2e S l e � — Awe Date UP TO 200 AMES
_GN Contmctm_j y p TSC' 2p1-1000 AMPS VY
�r ARC ITECPS DE LARATION
Z2 IuGI Yn�drentand my phru Il be ueedupubBe records OVER t000 AMPSLEWf,SQ.Ff.
a -e
ly��4``UU^ll.^ LI n Prm(MMkmaar SIGNSELECTRICAL pad
«6 OWNER-BUILDER DECLARATION K
In 7,� SPFGL1LCBtCU1T/MIST
71., I herebyaflmothat lamexempt fronthe Contractor's License Lawforthe
following reason.(Section 7W 1S,Business and Professloru Code:Any city or '
OF TEMP.METER OR POLE INST. 0-Qd
countyhichstructure
requ(res a is permit matter a uires th,Impmcant fo nWh,orret ir to
any assigned prior to statement
issuance,aLan rcdpursuart to onHorsuch peof t e POWER DEVICES
the a signed statement that he V licensed pursuant to the provhiona of the
3µ� Conlrasome.License Law(Chapter 9(commoncing with Section 7000)of Divi- SWD&MING POOL ELECTRIC VALUATION
O slon3 ofrhe Business and PmtealonsCode)orthat he is exem therefromand
the busts for the alleged exemption. Any violation of Section 70115 by any OUTLETS—SWITCHES-FIXTURES
applicant for a permit subjeem the applicant to a dvil penalty of nut mom than
NEW RESIDENTIAL ELECTR
five hundred dollars($500). SQ.FT. RUBIES TYPE CONSTRUCTION
R
�n I,as owner omf the Property,or my employees with wages as their sole
comp emation,willdothe work,andthe stccure is not Intended or offered for
Oin(Sec.7046,Business and Profemm loCode:The Contractors Doc.Law
$ does not apply to an owner of property who builds or Improves therecn,and
a who doessuch work himself orthrough Ns own employees,provided that such OCC.GROUP RFS.UNITS
Improvementsam not Intended muttered forests.lEhowever,thebuildingor - TOTAL QrOO
( Improvement hsoldwithlo oneyearofcomplMlon,the owner-bullderwlll have
tts.Lurden of proving that he did net bund or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
AI as owner of the property,am exclusively contracting with licensed_ PERMIT ISSUANCE
the
Contractor's
construct the project(Sec.of 70Kapp(Business Professions Code:
The Contractors esLicth a Lw dm fiat apply ct u owner of property who ALTER-DRAIN&VENT-WATER(EA)
I`l bu0dadents)
e Improves thereon, and who contacts !t.such ptokm with a FEE SUMMARY
ctor exempt
underpursuant mMe Contactors Llanee Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this reason
DRAINS ROOK ,AREA, .
SANITARY Y_ N_
Owner Date ROOFARGONDRECEIPT
WORK MAN COMPENSATION DECLARATION FORURES.PER TRAP SCHOOL TAX Y N_
hereby affirm that I have a cortlfiate o!consent roeel(-Insure,or RECpR•T N
difiate of WorkemCompemsrlonlnsuance ora cetifled mpythermf(Sec. GAS EA.SYSI•Q.f1 INCAOUTLETS PARK FTE Y N
3800,Lab CJ RECEIPT N
Policy N GAS F.A.SYSTEM-OVER 4(FA)
Company BUILDING DIVISION FEES
1 JCertIRM copy is hereby(umished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE $LIVER-&ANTEARY-STORM E.A.700FI• Date Remi t#
(Thissudlon need fiat be completed tithe permit laterom hundred dollars
(f100)or less) ENERGYFEE Y_
I certifythat lei the performance of the work forwhich this permit la Issued, WATER HEATER W/VENT/ELECTR N_
I shall not employ any person In any manner an as to become subject to the WATER SYSIEhf/TREATING
Workcn'Compensation Laws of California.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subject to the Worken'Compematlon provisions of the Labor TOTAL:
P
N Cade,you must forthwith comply with such provisions or this permit shall be BUILDING
W > deemed revoked.
CONSTRUCTION LENDING AGwcY SEISMIC FEE
1 G I hereby affirmthat there is a construction lending agency for the perform TOTAL: ELECTRICFEE to
Z arm of the work for which this permit h 97
Issued(Sec.30 ,Civ.C.)
U O lander'.Name PLUMBING FEE
LL F Lenders Address qN. MECHANICAL PERMIT FEE
O W 1certilythat]have read this application and statethattheabovelnfomaelon MECHANICAL FEE
0. 0correct.Iagrmtocomplywlthallcltyandcounty.Mil .ncesandk.telawa PERMIT ISSUANCEFEES PAID:
N relating to building construction,and hereby authorlu representatives.(this
city toenterupon the above-mentloord property for Inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,Indemnify and keep harmless the City of Cupertino Date R2CCIPt#
V gainsthabllitlm,prdgmenb,metsande.Exameswhichmzylnanywayaccrue AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
gairut said City In consequence oft granting of this permit.
"o(/` AIR HANDLING UNIT(DYER IO,OW CFM). CONSTRUCTION TAX
Signaturreo Applicant/Contractor r Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Reoei t#
material as defined by the Cupertino Munldpal Code,Chapter 9JZ and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yes No
Wlllthcappliant or utumbulldingocdrpanruseequipmenl ordevices VENTILATION FAN(SINGLE RESID) ISFJANBRDATE
which emit hazardous air contaminants as defined by the Bay Area Air /�I4i�
• Quality Management District? BOILER-COMP OHP OR 100,(X0 BTU) y A
qYa f—I No BOILER-COMP(OVFR100,000BTU) tt�
have read thehazar�i'nus materials requircmenh under Chapter&95 of T t
the Glifomla Health&Safety Code,Sediom 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that It R my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which at be rout PNN d.C(M6l�jRl�
prior to Issuance of a Certificate of Occupancy. M�
J
Owner or authorized agent Date TOTAL: ISSUED O -
.
OFFICE COPY