21882 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project identificationPRKMITNO.
O.
Belief Add 1 .
1882
Hera one;
oq �mhy CITY OF CUPERTINO-BUILDING DIVISION
Lie.No: APPLICATION I.PERMIT
47 Cip -«
Z Z BUILDINGELFCTRICAL-PLUMBING-MECHANICAL CATEGORY CONTROL N
Arehltect/Engiseer. L No:
,�pp.....a QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
y
Add �N PERMITISSUANCE ❑ ❑ Iia 1:1LICENSED CONTRACTOR'S DEC TION LP
I hereby affirm that lam licensed under provWon•of Chapter 9(co unare. APPLIANCE511ESIDENI7AL JOB DESCRIPTION
ingwlth Socha,7000)of Divisi.3ofthe BuM .and Prof.M..Cade,and my, {
License is in full force end Affect. PANELS
License Gla®
Date Contractor UP TO 200ANIPS I
201IODOAMPS
ARCHITECTS DECLARATION
00Zp Iundentand my plans ahaR be used as public recoNa OVER 1000 AMPS SQ.FT.FLOOR AREA S/SQ.FT.
b:
Licensed Professional SIGNS ELECTRICAL
a tC, OWNER-BUILDER DECLARATION
SPECIALCIRCUIT/MISC
I hereby.fifirm sson. that I am exempt from the d Prof ssio License LawAny for the
o following reason.(Section 70115,Buswessand Professions Code:Any city or S
OZ^c9 county which requlresa permit to construc"mr,Improve,derrolIsA,orrepair TEMP.METER OR POLE[NST. rV
�� aeystructure prlortolts issuance,aborequlresthe applicant for such permitto POWER DEVICES
ilio a Mgned statement that he Is licensed pursuant to the provlMme of the
3k� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
1- O Men of the W sines and PrefemloruCode)or that he is exempt therefromand VALUATION
fS�n s ted leaab for the alleged exemption. Any vldation of Section 7MIS by any OITD.EISSWITCHISFIXTURES
ct
�A applicant for a permit subjeathe applicant to a civil penalty d net more than
five hundred dollars($S00). NEW RESIDENTIAL ELECTR SQYT SI'OR16 TYI'ECONSIRIX:TION
�n F11,as owner of the property,or my employers with wager as theirsob
compensationwaldolhework,and the structure Is not Intended or offered for
OsaIs(Se,70K BuMneas arM Professions Code:The Contractors Lt..Law
3$ does not apply to an owner of property who Wilde or improves thereoq and /000.GROUI' RES.UNITS
whodoasuchworkhi lforthraughhi.ownempleyess,providedthatsuch
Improvements are not intended oroffered for sale.If,however,the Wilding or TOTAL:
improvement Is sold within one yearofcompletlon,the owner-W 0derw111 have
t1r. uMen of proving that he did not Wild or improve for purpose of wb.). Q7y, PLUMBING PERMIT FEE FLOODZONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE '7
contractors to construct the project(Sec 7004,Business and Profea ons Code: lzcz
The Contmeme.License Law don nm apply to an owner of property who ALTER-DRAIN k VENT (EA) C�
Wilds or Improves thereon, and ho and such p,eJeM,with• FEE SUMMARY
c,aEactor(M licensed pursuant to the Contncio'sLicense Law. BACKFLOW PROTECT.DEVICE
U I am exempt under Sec B k P C for this mason
OUTSIDE FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RDICEIn
WORKMAN COMPENSATION DECLARATION FO(111IffS PER[RAI' $CI100L TAX Y_ N N_
I'll hereby Affirm that I have•certificate of consent to eelLlnsurc,ora RECEIPT N
certificate ofWorkere Compensation lesuranm ora certified copythercof(Sec. GAS-EA.SYSTEM-1 WCAOUTLEFS PARK FM Y_ N_
35l bC � �N .��? ��d 9 REC=D
Pd Y fi 7 7 GAS EA.SYSTEMAVER 4(EA)
Com an BUILDING DIVISION FEES
ffCenifle e rel ed. CREASE/INDUS[RL WASTE INTERCEPTOR PLANC14ECK FEE
IxdC mf ad copy Is filed with the city Inspection division.
�����11 CERTIFICATE OF E)(EMPTION FROM WORKERS' GREASETRAP - PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date R, tat
(Thla section need not be completed If the permit Is forone hundred dollen
($IW)mle...) WA.I.� .I.�W/vEtrr/eLECIR ENERGY FEE Y_ N_
I certify,that In the performance of the work forwhich this permit is Issued,
I shall not employ any person In any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawes of CalifmnIs.Date PAID
0 Z Applicant NEW RFSIDFI-MAL PLM B. SOFT. Date Remi t#
Z O NOTICE TO APPLICANT.If,after making t his CenBiote of Exemption,you
should become aubkd to the Workers'Compensation provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this permit shall be U 'E
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
M G [hereby affiormtrwhiciethaermtmctlon lending ag7,Civ. .) perform. TOTAL; CYC ELECTRIC FEE
0 Z LeAdee Nwork(car whkh thio perMtIsblued(Sec.3097,Civ.CJ
U O Lender's Name PLUMBING FEE SAO
' U. H Lender'.Address QTY, , MECHANICAL PERMIT FEE MECHANICAL FEE
U Icenlfythat l have read thisappliatlonand ststethattheaboveinformation
0 W is carred.I agreeto comply with all city and county ordinances and Maw lam PERMIT ISSUANCE FEES PAID:
} R relating to Wilding construction,and hereby authorlu representatives ofthi,
N cit toents upon the above-mentioned property fmW ion ALTER OR ADDTO MECH.
~ Z y P pt1h' PM wrpO8G9 - Date R,xei Hi
— (W a to save,indemnity and keep harMen the City of Cupertbw
agai I Miles,' meat •a npenses which may In anywayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
ag old Art ting d thi.permit.
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX
Igna AppI n a Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
OUS MATERIALS DISCLOSURE
Illtheapplianl or future Wilding occupant store or handle haaardous HEATING UNIT(TO 100,000 BTU) Date ReceI til
material as defined by the Cupertino Municipal Code,Chapter 91Z and the
Health and Safety Cade Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL: , aQv
❑ Yea , No
Will the applicant Sam Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$�WATE
whicBtimlt hanrdous ah cents Mrant.a.dented by the Bay Area Air
silty Management District? BOILER-COMP OHPOR 100,000 BTU) A1991
uL��Yca ❑No t:"i Q fJ 8 1891
I have read the hamNous materials requirements underChapter Q95 of BOILER-COMP(OVER10f1,000BN) 6
the Callfomb Health la Safety Code,Sections 75505,25533 and 25534.I
understand that if the building don not currently have.tenant,that It Is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to not lfy the occupant of the requirements which must be metfIL
prior to Winne of a Ceniticam of Occupancy.
Ownerorauthoneed agent Data TOTAL: ISSUEDBY:
OFFICE COPY
C