22535 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bu�� Protect Identification '^w ' I ~ PERMIT NO.
e1V 22535
a : one: q
1 NO 10
cy CITY OF CUPERTTNO BUILDING DIVISION
° mattnr'.m m: Lie.N. APPLICATION I PERMIT J C
�- BUrLDINGML TRICAL-PLUMBINGMECHANICAL CATEGORY CONTROL If
Archited/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreu:. - PERMITISSUANCE 2. � El El
CONTRACTOR'S DECLARATION
Iherecctiormthetlam gcmndud usiremsndPre Chapter9de,tod a APPLIANCESRESIDENML JOB DFSCRIIPIION
InerstlSI f uf000)of Dlvlstm3o[the BusineaeandrrofeulonaCode,and my
license bin fu� u(9rre and erred ` � PANELS w 1 /� /
Llcen 1^ IS LICM '/1nVl �`.3']•Y'Y'(// (/
Dale S�Contn
ARCHITECT'S DECLAR ION 201-IOOGAMPS
�❑u O ZOCO I understand my plans shag be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
F d U Licensed Profess beat SIGNSELFCTRICAL
GGGG OWNER-BUILDER DECLARATION SPFLGLCIRCUIT/MLSC
Z•�' 1lurebyaflme that lamexempt fmmlhe Conirattore License Lawforthe
following reason.(Section 7031.5,Business and Professions Code:Any city or
F TEMP.METFITOR POLE INST.
,a
county stmeneh rcqulma permitso theaprovgdemolbh permit
tto
q anystmtturetatemenprior to tahat heisa oresed restheat to the forisions of to POWER DEVICES
file a signed statement that he b gceneed pursuant to the provisions of the •
Q6 3µO ContnRo/s Lkerue law(0Mpter9(commencing with Settlors 7qD)of Divi- SWIMMING POOL ELECTRIC
don3o(the Bustnese end Pro(emlom Cde)or Nat heb exemprtherefromand 0 VALUATION Q the basis for the alleged exemption. Any violation of Section 70315 by any OUTLEISSWITCHESFIXTURES applicant for a permit subj mthe appticant to a civil penalty ornet more than❑ve I,as dddbnheproNEW RESIDENTIAL ELECM SQ. . TYPE CONSIRUCHON
❑1,as owner It the property,or my empbym with wage a•thele•olecompensation,B..1omhe work ite the.[rude:Thi rwt intended or offered for
k(See 701E Bu•busaand Pro(mloru Cde:The Contnctola Llcenu law
$ doe•not apply to an owner of property who builds or Improve•thereoM andOCG GROU':'
RFS UNITS
EE whedoessuehworkhi.if.rthreugh Naownemployee•,provlddthatwu h p
Improvemenb sre not intended oroffered forsale.If,however,lhebulldlng or TOTAL; _V
Improvement Issold withinoneyearofcompldiomtheowner-bullderwlll have
Ue�urden of proving that he did rut build or improve for purpose ofnln). QTY PLUMBING'PER'MIT"\ M pLOpp 7DNE ArN
Lj L as owner of the property,am exclusively contracting with licensed PE*dlTI55UANCE
contractors to construct the project(Sec.7044,Business and Proressloro Code: I _
The Contnaor's License law don not apply to an owner of property who -DRAM&VENT=WATER ',j
Wilds or Improves thereon, and who contracts for such psujem with a I e FEE SUMMARY
gNf,dor(s)licensed pursuant b the Contractors License Law. BACK FLOW PROTECT.DEVI
c LJ I am exempt under Sec B k P C for this reason il
DRNN - R(qP;AAEA, SANITARY Y N_ _
• Owner Date RECmPI'N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y N
❑i hereby orfirontkent that I have•certificateInsurance
of consent to op6insurc,ora - RECEIPT If
certificate ofWorkere'CompemaHanlmunncemaartl(kd copy thereof(Sec. GAS PA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
38310,Lb CJ RECEIPT N
Polley N GAS FA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
��Ce Ifid copy L+hem (umlehd. GREASE/MDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
rti0ed copy V filed with the city ImpecHon divinlon.
CERTIFICATE OF EX( PTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA cwt 1. Date Recti H1
(This section need not becampleted tithe permit is forom hundred dollare
(310R)mless.) WATER .t.�ly/vENr/o.ECIR ENERGY FEE Y N
I cortlfythat 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'Compe cation Laws of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recti t#
O NOTICE TOuldbe.APPLICANT. aRernakingehtsmionprteof Exemption,yrs,
should become subject to the Worken'Compematlon proWiom of the Labor TOTAL:
N Code,you must forthwith comply with such provislau orthb perrot shall be BUILDING .O
W 5 deemed revoked. '
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyafRmo that there is.construction lendingagerey for the perform TOTAL: ELECTRIC FEE Q
Z ance ofthe work forwhich thin permit Is Issued(Sec.3097,Civ.C.)
V O lender.Name PLUMBING FEE
LL, — Leders Addmes QTY. MECHANICAL PERMIT FEE MECHANICAL FEE o
OW 1certifythat l have read thi•applicatbnend state that lheabove Information
EL i•conect.Iagreeto comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} fA relating to building construction,and hereby authmlee representatives of this
cit to entero n the abovementbned propertyfor W Ion ALTER OR ADD TO MECH.
~ Z y(We)agree to save,Idemnlfy an d eermless the ity of Cu rtlno Date Receipt#
V agalat liabilities,judgments,costs and expenses which my In any way accrue AIR HA NDLING UNIT CIO 10,000 CPM) SUBTOTAL'
against mid City In consequence of the granting of this perms. AIR HANDLING UNIT OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appunnt or future building occupant store or handle havardous HEATING UNIT(TO lOg000 BTU) Date Recei t#
material m defined by the Cupertino Municipal Cde,Chapter 9.1 2,and the
Health aed Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
qY. LNo
Ill the applicant orfxture building occupant use equipment or devices VENTILATION FAN(SINGLE REED) ISSpavCFEPATE
which emit hamrdous air contaminta as defined by the Bay Area Air
Quality Management District? BOILER-COMP PHP OR 100,0W BTU)
ye,rood
�s/T
have read/hahazardous nulerlals requlrerrentsunder Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ��(T
the Califomla Health k Safety Code,Sections 75505,25533 and 25534.I If! Y aGs
understand that lfthebuildingdo sewcurrentiy haveatenant.that It lsmy, NEW RESIDENTIAL MECH. SQ.F7
responsibility to notify the occupant ofthe requlrementswhich mustbemot �n.,Cup"
prior to sasuancoof a Certif tate of Occupancy. 111R
OwneSor authdeed agent Date ISSUED BY:
TOTAL:
OFFICE COPY