22700 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PPRMITNO.
BuildingAddress: F H 7)2 S3 133 o 22700
��n r9 One:
CITY OFCUPERTINO-BUILDING DIVISION
tr'"nr' / • LIc.No: APPLICATION / PERMIT ( `
aAAAU Db / BUILDINGE,ECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL#
iters/Engineer. LM.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address —
PE MITISSUANCE s� ❑ ❑ ❑
urnby a that
LICENSED CONTRACTOR'S UEions of TION LFT'
IMrecctJ..7")o Div son Bcmsedunderpicasanosof ChaptsCodeamenc AIPIPLIANCESRESIDENTIAL JOB DESCRII'l]ON
time.hSection p00)o(d affect
eon3a(the Businevand Pro@sslonaCode,and m
Brent Isla fuB,1( deflect. PANELS �1
Liren CWss 4o CH#� d'
Dale Contactor ri •�f- pt-SWOAMPS
ARCHITECTS ECLARATIOr MPC. OVERIMOAMPS
ZC [understand my pure shall be used sspublic records SQ.FT.F7AOjt ARF � f/SQ.FT.
fs Licensed Professional SIGNSELECTRICAL L E D
<�. OWNER-BUILDER DECLARATION1here
yarm tfromthedorblaw fort he
SPECIALCIRCUIT/MSC
Ofollowing reaser.(Section
7MI3, tress and Prefos Code:Any or
p /U®�T�ER
CP' countywhlchrequlrempermittocoiostmd,alter,Improve,tlemolLsh,orrepair TEMP.METER OR POLE INS?.
3 .� anystm=mpr rto Bsissaame,aLsorequematheapphcantforauchpermitto POWER DEVICES
O. file a signed statement that he b licensed pursuant to the provisioro of the �---
k Contractor's LNccrue Law(Chapter9(commencing with Section7000)of Dive- SWIMMING R70L ELECTRIC
ston3olthe Businessand Proles CWd )arthathebemmptthemfromand VALUATION
the basis for the alleged exemption. Any ,violation of Section 70315 by anyD -�
applicant for a permit subject9the applicant toacivil penalty of nor mom than OUTLETSSWITCHESFIXIURFS
o. o five hundred dollars WOO). NEW RESIDENTIAL ELECTR
..�n 2011,
❑I,as owner of the property,or my employees with wages m their sole SQFr. ES TYPE CONSTRUCTION
compensatloq welldothe work,and thestructure b not Intended or offered for
$IL 0 sale(See.70EE,Bu9lnessand Professions Code:The Contradoes Umes,law
O$B does not.pply toan owner of property who Wilda or improves thereon,and RF UNITS
OCC.GROUT'
who does such work hemseV or throxi his owe
n mployees,prov id ed tha t such
ImprovemenU are not intended mothered forsale.If,however,thebuilding or TOTAL:
ImprovementL widwithinoneyearofmmpleloNtheowner-bullderwillhave
th rden of proving that he didnes bund or improve for purpose ofsale.). QT-y. PLUMBING PERMIT FEE FLOOD ZONE MN
Lj L as owner of the property,am exclusively contracting with licensed PERMRISSUANCE
contractors to construct the project(Sec.70th,Business and Professions Code:
The Contractors License haw does not apply to an owner M property who Mq�DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contmem for such ptojeds with a
cq➢If.dor(s)licensed pursuant to the Contmetre.License Law. asBACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B&P C for this mon
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
O WORKMAN COMPENSATION DECLARATIONRECEIPT#
F-11 hereby affirm that I have a mrtlBcate,of consent to self-Insure,or a FIXTURES PER TRAP SCHOOL TAX Y N
certificate O(Workers'Compe timil ranaorattrtlf4 copythe.f(Sec. RECEIPT
3800,Lab C.) GAS EA.SYSTEM-)INCE OUTLETS PARKFEE Y N
Policy p If
cn^pany p GAS EA.SYSTE.t-0VERd(FA) DING IV
ffccruOed-cp(Y.execby fumishN. BUILDING DIVISION FEES
❑Certified pyisfiledwkththeeftyempectiondevis On. GREASE/TNDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEM PTION FROM WORK ERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 2057 Date Recei t#
(Thlasedlon need nal becompleted If the permit V(Drone hundred dollars
(ft 00)orless.) WATER HEATER W/VENT/ELFTTR ENERGYFEE Y N
Ittnot that o the person
any terworkmanner f,as to h thea),subject
blued. —
I slake not employ any person In any manner m ss to became subject to the WATER SYSTEM/TRFAHN'G
Workers'Compensation Tawe of Call(ornla. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:If, oflon'k o this Compensation
cafe o(Exemptlon,you
Fshould Wcomesubjed to the Workers'Compersallon provisiomoflhe Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be
LU > deemed revoked. BUILDING FE
(L c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a comtrudeon lending agency for the perform ELECTRIC FEE
7 ZO anco of the workfor which this,permit v houed(Sec 3D97,Civ,C.) TOTAL:
L) Lender's Nacre PLUMBING FEE
LL ~ LendereAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W (certify thatl have read this application and uatethat thea—e enformation
1 iscorrect]agree to complywlth all city and county ordinances and state laws PERMIT ISSUANCE PEES PAID:
} N relating to building construction,and hereby authorize representatives of this
In city to enter upon the abovementloned property for inspection pu reuses. ALTFRORADDTOMECH.
V — (We)agree to save,indemnify an d keep harmless the City of Cu perteno Date -Receipt#
a alnst llabil)ties,judgments,cosrsand expenses which may In anywayaccrue AIRHANDUNGUMTO0CFID
O10,00SUBTOTAL:
inat acid Cit Nn m of the granting of this pe I[.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
17CIfton,Of Applicant/Contractor rDate
EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA ERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFATIN'GUMT(TOIDg000131U) Date RCCeI t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Hx.1th and Safety Code Section 25532(.)7 HEATING UNIT(OVER IW,"BTU)
[71 yea �]No TOTAL:
Will the applicant or future Wilding occupant use equipment or devices VEN[LATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4Y,, FF��No
have readthe ha arVousmateriabrcqulrem nbunderChaper6.95o( BOILER-COMP(OVER 100,000BTU)
the Califmnu Iicalth&SafetyCode,Sectioro 25505,75513 and 255M.I `
understand that notify the occupant
of
erequire encs tenant that it met NEVI RESIDENTIAL MECH. SQ.FT I.rk
responsibility cin faCereoaupantoftherequvements which most be met ]Aes�
prior to Lssuance ofaCertlli<ate of Occupancy. y_ Ia7 aJ
Owner or authorized agent Date ISSUED 11Y. l
70TH L:
OFFICE COPY