22237 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
B"fid"gAddrei r 22237
i � o � ��fz � ,�
one: p
CITY OF CUPERTINO-BUILDING DIVISION
c°ntrs"°:°Name: Lic.No: APPLICATION /PERMIT (P
101,DINGELECTWCALaUMBING-MECHAN'ICAC CATEGORY CONTROLN ,
rchltect/ gtneer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERh11TISSUANCE 'jam 1:1ElLICENSED CONTRACTOR'S DECLARATION ]
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES RESIDENFIAL JOB DESCRIPTION
ingwith Se ion7000)of DiAsion3ofthe Business. dPmfes msCode,and my
li d e<fen. !L G o PANES FIRr.. C�- R
License Clan Ic.N E+ /,4I
Date Contracmr r ,!'li!—
ARCHITECTSDECLARATION 201-10DOAMPS
LqqL�ModO ZI understand my plans shall he used as public records OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fi � Licensed Professional SIGNS ELECTRICAL g L E D l
«<< Iu DI OWNER-BUILDER DECLARATIONVP
Z,'4 I herebyaffinmthat I mcxempt(rom the Contractor's License law forthe SPECIALCIRCUIT/MISC
following reason.(Section 7W 1.5, omtmBusiness and Professions Code:My.p or p
t'[9 following
rearequires.per031.5, snan professions
Code:Any
or TEMP'METER OR POLE INST. 'V'
P''� Caj any.tm[ture pnortolts Issuance,also requiresthe applicant forsuch permit to POWER DEVICES
�M V file a signed statement that he V licensed pursuant to the provietons of the I
I SOp, Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- {,
Os slon3 ofthe Business and ProfessioroCode)orthat he is exempt therefromand SWIMMING POOL ELECTRIC
the basis for the alleged exemption. Any violation of Section 70115 by any I
< appBant(ora permit subjectsthe applicant to a civil penalty of not morethen OUTLETS-SWIT'CHFSEXTURES
c. o live hundred dollars($SM. NEWRESIDENTIALELECTR FT. EFLOLNF.
N
�r ❑I,as owner of the property,or my employee with wages as their sole _SQFT. TYPE CONSTRUCTION
� < compensation,will do the work and the swcture is not intended or offered for
9 D sale(Sec.7041,Business and Professions,Code:The Contrado/s License Law
j $ does not apply to an owner of property who builds or improve,s themon.and OCC. RFS.UNITS
who doeasuch work hlmselt mthrough his own employ.,provided that such
Improvements are not irmode i m.f@red Jangle.l(hmveveg thebullding or TOTAL:
improvement lsaold withlnoreyearofcompldli theowner-bu0derwill have
th rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEEAPN
I,as owner of the property,am exclusively contracting with licensedcontractors to construct the project(Sec.7016,Busin.and Professions Code: - PERMIT ISSUANCE
TheCotractoes License Law d.not apply to an owner of property whoALTER-DRAIN kVENT-WATIIt(EAI
buBds or Improves thereon, and who comracts for such Alois b with a<gDII ctor(s)licensed pursuant to the Contraaor'e License Law. MMARY
LJ I am exempt ur aer sec B h P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N—
Owner Date RECEI'T
WORK MAN COMPENSATION DECLARATION 1I
FIXTURES PER TRAP SCHOOL TAX Y_ N
❑I hereby affirm rlum,that I have ocertificate,Ensucof consent to op thaure,ora RECEIPT N
cenillLab ofWorken'CompemaHonlrsuranmora unified copy thereo((Sec. GAS E.A.SYSTEM-1 INCA OUTLETS
3800,Isis CJ - PARK FEE Y N
Policy p RECE77 p
Cam any GAS IA.SYSTFM-OVERd(FA) BUILDINGDI VISION FEES
Certified copy is filed hereby
thehM. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy V(fled with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCEpANCE SEWERSANITARYSTORM EA 200FT Date Recei t#
IThis.ectlon need nu br completed lithe permit Isfor oro re
hundd dolls.
(8100)orlassJ WATER HEATER WVENERGY FEE Y N
Irertlly that in the performance olthe work for which mit ch this peris issued / ENT?/ELECTR —
I shall not employ any person in any manner so as to become abject to the WATER 5YSIEM/TREATING
Workers'Compensation Tawe of California.Date
0 PAID
Z Applicant
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Remi t#
CC fA
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Code,you=at forthwith comply with such provisions orchis permit shall be
LU > deemed mvoked. BUILDING FEE
a O CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them isa corL9trocion lending agency for the perform
7 Z arm of the work which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
U O lender.Name PLUMBING FEE
LL F Lendee.Addree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
0 W 1certifythat l have mad thisappllahrnand date thatthe aboveinformation
S brorrect.I agree to comply with all cityand county ordinances and date laws PERMIT ISSUANCE FEE$PAID:
} U) relating to building construction,and hereby authorize representative of this
F Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MFCH.
— (We)agree to save,indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,udgments, As and expenses which may in anywayacwe AIR HANDLING UNIT(TO 10000 CFM) SUBTOTAL:
agal Id CityBsure uen of the grant grf 1.permit.
7Ar—A7�./ NRHANDLI G IIMT(OVER 10,0(sOCFM) CONSTRUCTION TAX
Slg7ahAeot Applicant/Cont rDate IXHAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLO RE
Will thcapphcant or future building occupant store or handle hazardous HEATING UNIT(TO 10,000 BTU) Date Reed f#
.tedal as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(')? HEATING UNIT(OVER 100,000 BTU) TOTAL:171Yea M No
Will the applicant or comm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) �jl (•1ANCE DATE
which emit hazsrdom air contaminant.as defined by the Bay Area Av
Quality Management District? BOILER-COMP QHP OR 10,000 BTU)
Yemad ❑No jug I O 198
havCJ-11h-th&SOusmatISa i-u25505tsunder Chapter6.95 of BOILEt-COMP(DVER 100,OW BTU)
the Glifornla Ficahh k Safety Code,Sections 25505,21533 and 25534. I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT rik�
resporsibillty to edify the oavpant of the requbemnnts which must be met lga�r el'esc
prior to Issuance of a Certificate of Occupancy.
Owner or authortud agent Date
TOTAL: ISSUED BY�I
OFFICE COPY