22139 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMWT NO.
Building Address: -
I�s �L�,es�af �n 22139
woers ams: one: APPLICA HUN bUUMII IAL UA II,
'r• Or CITY OF CUPERTINO-BUILDING DIVISION
GantractersNa : LIc.No: APPLICATION I PERMIT 1
CYI I BUILDINGELECTRICALPLUMBINGMECIIANICAL CATEGORY CONTROL#
Architect/Engineer. .. - Lk.Na.
Q'rY ELECTRIC PERMIT' FEE BUILDING PERMIT INFO
Nrrzrr—
Address: PERMITISSUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Lomsed under provisions of Chapter 9 immanent, APPLIANCES-RESIDENTIAL JOB DESCRIPTIONIngwll Id d(eSectfan700).( fie on3o(the BustrsesandPre/easloneCade,and my `
lirensc is In full to and ct. � PANELS
I.Icenne ism Lk.N 1 ^
Dale antrwor t s.w
ARCHITECT'S DECLARATION 201-1000 AMPS
flz I understand my phvehall beused a a publicremrds. - OVERIWOAMPS SQ.FT.FLOOR AREA S/SQ.Fr.
[Tsui Licensed Professional SIGNS ELECTRICAL'
OWNER-BUILDER DECLARATION
1`m} SPFCLILCIRCUIT/MISC
z,l-"GI Iherebyasorm thatin 7exemptImrethed Contractor's License Lw(orthe -
po county which
requireNon70t tom arses and Pimprave, Code:Anycityor
TEMP.METIR OR POLE INST.
cauntywhich requiresa permitmmnstmct,alter,lmpreve,demolish,orrcpalr .
anystmciurc pdortoltebsuance,afro requlreslheappBant!.Pesch permitto - POWER DEVICES
file a signed statement that he is licensed pursuant to the previsions of the "
3w Contractor w
'sLlm.la (Chaper9(mm
meneingwith Section 7000).!Divi. SWIMMING POOL ELECTRIC
�0 slon3 ofthe Business and Profeob m
lonsCode)orthat heeaepmVALUATION
therefromd _ (;—(DO 10i the basin for the alleged exemption. Any violation of Seaton 7015 by any
G£ applicant for a permit subjects the applicant to a civil penalty of nmom than OUTLETSSWITCHESFDETURES
$ five hundred delta.(SM. NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSERUCTION
7a I,as owner of the property,or my employees with wages as their sole
compensation,Mlldothewmkendthestmmrebnalntendedor o(feredfor
O sale(Sec.704q Ruslneae and Professions Code:The Contractors License Law
does not apply to an owner ofproperty who Wilds or improves thereon,and OCC.CROUP RES AMTS
who does such work himself or through hlsown employees,provided that such
Improvements are not intended mattered forsale.If,however,the building or TOTAL: -
improvement bsold withlnoneybarofcompletion,theowner-budderwlll have
thc1rurdenof pmvingthat he did not bulldorlmproveforpurpowofsale.). Q7y, PLUMBING PERMIT_ FEE - FLOOD ZONE APN
(_f{as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sm.7664,Busmen and Pra(easlonsCade:
I he Contractor's Lkeoae Law does nor apply to an owner of property who ALM-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such pVujecta with a
c0.Hs)licensed pursuant to the Contractor:License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY :
LJ I am exempt under Sec B&P C for this mason
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N
Owner ' - Date -
WORKMAN COMPENSATION DECLARATION RECEIPT if
k•� ❑1 hereby a((irm Mat 1 have•rerti of consent m aelf-tnwrc,ora FIXTURES PER TRAPSCIi00L TA% RECEB'r#
S
rertiflateol Workers Compnnsatlanlnsummranmmaarti!led mo
cepythef(Sm. CAEA SYS'1'EMi INCA OUILErS PARKFE31 .Y N
380,Tab CJ p
Pollryp CAS EA.SYSTEM.OVER 4(EAI DINGRECEDI VISE
Com env }AFP F, .-.r BUILDING DI VISION FE ES
Certified ropy b herebyth the city CREASE/INDU5TRL WASTE INTERCEPTOR PLANCHECK FEE
,- �Certllled mpybflled with the city inspection dlWslon.
CERTIFICATE OFEKEMPTION FROM WORKERS' GREASETRAP " PAID _
COMPENSATION INSURANCE SEWER-SANITARY STORM FA.20DFf. Date
Reeel 1#
(TMssedlonne nabecompleted BtMpermitblocomhundreddollam
O70)mlceeJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I certify that In the performance of the work for which this permit le issued, ,.. -
1 shall not employ any person In any manner no w to become subject to the WA'RBt SYSTEM/TRCATING
WorkeW Compensation Laws of Califumb.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
Z O . NOTICETO APPLICANT-.If,after makingthla Certl(Iate of Exemption,you
should bemrmsubject to the Worksrs'Comperuatlon pmvldonsoflhe Labor - TOTAL:
tl2 Code,you must forthwith comply with such providers or this perdt shall be
LU > rimmed revoked. -BUILDING
.a p CONSTRUCTION LENDING AGENCY SEISMIC FEE , t a
I hereby alfirm that there is a construction lending agency for Me pedorm ELECTRIC FEE
7 Z anm.ftheworkfarwhlch this permit In bsued(Sec.3097,Civ.C.) ' TOTAL: i
O O tanderb Name PLUMBING FEE
LL H Lender.Addmna QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
,O W I ced ify that l have read this appllatlon and elate that the above information
1 bmrrea.l agmeto comply with all cityand ceuntyordlnanreaand slate laws PERMITTSSUANCE FEES PAID:
T relatingtobuildingmmtmctlon,and herebyauthmizs rcpresentativesafthis -
Zcity to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADDTO MFCH. Date BOCCI f#
(We)agree to save,Indemnify an d keep harndew the City of Cu Perrino - P
against listillu Ica,Judgments,mks and expenses which may In any ayaccme AIR HANDLING UNIT(TO I Q00 CFM) SUBTOTAL:
against city,Inconsequence. ting. thl permit,.
AIR HANDLING UNIT(OVER I0,000CE.t) CONSTRUCTION TAX
:I of p Iant/ mractor ata E)1HAUSTFIOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA DOUS MATERIALS UISCIA R
Will the appllant future building occupant store or handle hazardous HEATING UNIT(T010,000 BTU)
material as defined bythe Cupertino Municipal Code,Chapter 9.12 and the. Date RCCeI 1#
Health and Safely Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
F1Yes No
WBitheappliantm tumbuildinfloavp.m..eq.1pmerd ordevicea VENTILATION FAN(SINGLE RESID) ISS ANCE DATE
which emit hazardous air c.ntaminants as dented by the Bay Area Air
Q�Ealtty Management District? BOR.FR-COMP OHP OR 100,00 BTU)
Yca read the
No ,
lhavce bazar9ousmaderlab mqulrcm,,mx uaderCha pter 6.95 of ROLLER-COMP(OVER I00,000 BTU) ���;,
the California health&SafetyCode,Sections 25505,have
a tenant,
and 25536. I
understand that if the notify
the ing doescompact of to reuiyhaves which mustb ismy NEW RESIDFN'RAL h(ECH. SQ.F7 V
responsibility to notify the.cmpant of the rcquiremenin which must be met
prior/.bivance ma Certlllate of Ocapanry. L'�jL-�a�-_..
Owner orauthorlad agent - pate ISSUED BY:
TOTAL;
OFFICE COPY