22815 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PF MTNO.
Building Address: JOIN � _ •a 22815
eyR�I �co .
wee are:
A A
(;6 ,%Z" CITY OF CUPERTINO-BUILDING DIVISION
ContraanraName: /�/ Lk. APPLICATION If PERMIT
`� b 1 r BUILDING-ELECTRICAIIPLUMBINMFLIiAMCAL
G- CATEGORY, . CO L it
Architect/G neer. Lk No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: BLUU "ELI
PFRAfITISSUANCB^' ❑ ❑ �' ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affUm that l son licensed under provisions of Chapter 9(commene APPLIANCESRESIDENIIAL JOB DESC ON
Ingwlth5 dion7000of Divblon3ofthe Budneeeeeeggqqqqsss...and PrefesslonsCodeandmy, ;
LI.licen.la ie(uB(ores and d(ectPANELS
Llcen.Ctan LILY YLL 1
Date Contractor 1 1
ARCHITECTS DECLARATION 201-1000 AMPS
{Q�OCO I understand my plans.hall beused.public romrds. OVERILOBAMPS SQ.Ff.FLOOR AREA S/SQ.FT.
Licensed Profeselonl - SIGNSELECTRICAL HALED<�¢' OWNER-BUILDER DECLARATION S['ECIAL CIRCNT/MISC p /t p�
7 owing earen.affirm thallamexeTpt...from .Contractor's License La.Any for the �\V/' 11�+ C
oo
following r n.(im a p 7 t to us d;dternd imevkns emlCode; ,y city pair
O Z'" TEMIa,METER OR POLE INST.
�� ceuntywhich requlresepermit tocontmct,ilter,lmprova,dernikh,orrepalr �♦ p
q a nystructurepriort ttaissuance,also requlrestheappllesntfonuch permit to POWER DEVICES DA K /,
[5 O file a signed statement that he k n licensed pursuant to the provisions of the
GFj1 �� Conractore License Law(Chapter 9(mmmencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC
akm3efthe Buaffim and Pmfembn Cods)orthat he i.exempitherefmmand VALUATION -
4 the basis lorihe alleged exemptlon. Any violation of SeOlen 70315 by any OUTLETSSWITCHESFIXTURFS
applicant fora Fermat subjects the applicant to a civil penalty of net more than
five hundred delta.(SM. NEW RESIDENTIAL FIFGTR
❑1,as owner of the property,or my employees with wages as their wk SQFT. STORIES TYPE CON61 UCTION
'ry� compensation,will d o the work,and the structure is not intended or offered for
JF OO .ie(Sec.7064,Business and Profession Code:The Contractor's License law
does not apply to an owner M property who builds or Improvrs thenen,and OCC.CROUP RFS UNITS
who does such work himself orthrough his own employees,provided that such
Improvements are not Intended oroffered forests.If,however,thebullding or TOTAL:
Improvement ksold withlnoneyearofcomplebn,theownenbullderwillhave -
OW-Iladen ofpmving that he did notbuildorimproveforpurpo.eofuk.). QTY. PLUMBING PERMIT FEE
LJ FLOOD ZONE APN
4 as owner or the property,am.7044, rtyBusiness
ess and ing Professions
Ilren.d PERMIT ISSUANCE
contractors tocentmnthe project(Sec,apply
to an
of prop.Code:
The Contractor's License Lw does not apply comment f owner of property who ALTER-DRAIN k VENT-WATER(EA)
bu iTa t r Improve thereon,and setaeftdoemfor such p(e)so with a
oqn¢+ctoK-0 Bcensed pursuant to the Contnctora License Law, FEE SUMMARY
LJ[am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE!
DRAINS FLOOR RSANITARY Y N
Owner Data
RECEIVEOOF,AREA,COND.
WOR"MAN COMPENSATION DECLARATION I•ANRES PER TRAP SCHOOLTAX Y N
❑I hereby affi m that I have a certilkem of consent to self-Insure,or �/ RECEIPT
certificate of WorkerYCompenadan lnuranceera cedlfled copythereof(See.
3800,Lab CJ GAS FA SYSTEM-1 INCA 0UTLEfS PARK FEE Y N
REC
Policy M GAS EA.SYSTEM-OVER 4(EA) DING DIV
T N
Cam any BUILDING DIVISION FEES
copy k heed with thehed. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified mpykllkd with the dty,inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERY _ GREASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY .
Rhksectlooneed notbecompleted lftheperndt lsforons hundred dollars STORM EA1200Ff. Date .Roma til
($100orleaJ WATER HEATER W/VENT/ELECTR , ENERGYFEE Y N
I certify that In the performance of the work forwhlch this permit is issued, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM Workers'Compensation Laws of California.Date PAID
0Z Applicant - NEW RESIDENTIAL PWB._SQFI. Date " Remi IN
Z O NOTICE TO APPLICANT.If,after making t his Certificate of Exemption,you
should bameesubjcct to the Werke.Compensation provision fthe Labor TOTAL:
N Code,you at forthwith mmplywithauch provision or this perMtshell be BUILDING
W > deemed revoked. FEE
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lend Ing agency forthe perform ELECTRIC FEE
7Z ance of the work for which this permit la issued(Sce.3097,CIv.C.) - TOT
V O I..der's Name , PLUMBINGPEE
-
LL H Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICALFEE - -
O,W lredifythatlMvereadthlsappliwtionandgatethattheahavelnfarmatlon
1 Is correct.I agreeto comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID: -
W relating to building construction,and herebyauthorim repmaretativesofthts '
1" Z City to enter upon the ax,v n mtkned property lar Wpection purposes. ALTER OR ADDTO MECEL Date Recel f#
V (We)agree to save,Indemnlly and keep harmless the City of Cupedlno F
against liabilities,Iadgmente, d caper..which mayle anywayaaciue AIRHANDLING UNIT(TO I0,0D0CFM) SUBTOTAL:
0 t Id Cityln(Snearye o(t granting of this permit.
_rY��_V�4,_-�['��• AIR HANDLING UNIT(OVER lB,aooCFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAlARDOUS MATERIALS DISCLOSURE
Will the applicant orfuturc building occupant atom or handle hazardous HEATING UNIT GO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.I2,and the - .---
health and Safety Cade Sedlon 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL.
❑ Yes r]No
Will theapplicant or future building occupant u.equlpment ordevices VENTILATION FAN(SINGLE RFMD) ISSUANCE DATE
which emit harard0115 air con.elnants as dellred by the Bay Area Air -
• Ilty Management District? BOfLER-COMP 0EMOR 100,000 BTU) ` -D;
4YroF1 No P-J
Y.
read the haze out.Code, eroqulremenbundeand 2554. 1 of ROB.ER-COSIP(OVER 100,000 BTU) CAS Q
the Gllfornla Health&Safety Code,Section 75505,25533 and 25534. I 3 19.71
mpontand Nat notify
the occupant of the requirements
which
that it key NEW Ij15IDFN77AL MECIi. :Q.FI GCT
responibllity to ndlty the occupant of the mqulremenb whish must be mel ,
Adam to lssuanre o/a CertlBcate ofOccvpancy.'
p
Owner or authorized agent Date
- TOTAL: ISSIIF.DB
OFFICE COPY