22118 (2) APPLICANT•TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY.
Building Proed Identification PEILWTNO.
Bulldindrtn,:
1 `1 am�. Q. - a 2 211.8
a arae° ane' A A A
�fp- - CITY OF CUPERTINO0.BUILDING DIVISION " /
ante �tl: a: APPLICATION /PERMIT
n� Tom/ BU[LDINC-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CONTROL'X
Architect/Engines Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address - PMMITIS5UANCE ❑ ❑ ElLICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam licensed under provWonaof Chapter 9(commeno. APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith5ecT 7DW)of Dlvlslon3ofthe Bualnessand Profs sionsCode,andmy
license lsln fes cited. Q PANELS -
Date CfUTctom ]CL 0 1'n InT� UP IQ 201thms
ARCHITF.CTSDECLARATB rd OVER00AMPS
q�q�uu�ZO I understand my phna ehaB 6e used u public records OVER 1000 AMPS � r�"{FLOQR� $/`.Q.FT•
it �j Licensed Professional SIGNS ELECTRICAL U I
�,`a�° OWNER-BUILDER DECLARATION , SPECIALCIRCUIT/MLSC u T E R
Z,�? Iherebyaf).that IamexempfromlheContractor'sLicenseLawforthe
following reason.(Semon 7,xlol Business and Professions Code:Any city or
O O TEMP.MEIGR OR POLE INST.
rr countywhkh requlresa pemdttoeorutnct,ilter,impmve,demolbh,orrepalr G
a eysWcturepAcutolblswarace,also requiresthe applicant formch permit to ROWER DEVICES
E5 file a signed statement that he is licensed pursuant to the provisions of the r
fQj 3 u, Contractor's License Law(Chapter 9(commencing with Section 7000)of DIA- SWMMWG POOL ELECCRIC
�0� the
too WINfo th..1leand xemption. Any iolatiorthan fSectiexempt therefrom and _ VALUATION
the bean for the alleged exemption. Any violation o(Sedlon eat15 by any OUTLETSSWITCHES-FIXTURES
<$
applicant.dmdd.tI rs 550B. eche applkant too civil penally o(nd nnrethan
c. R five Landowdollarshepr.
QQQ . NEW RESIDENTIAL ELECTR
I,as owner of the property,or my employees with wage as/hetr sok —SQ'FT' STORIES TYPE CONSTRUCTION
�7a
on if the work and theetructum Is not intended or offered for -
O sok(Sec.704y Box=and Pmfeasbw Code:The CmAradors Lt..Law
S docs not apply to an owner of property who Wild.or Improvise thereor,and - OCC.GROUP RFS.UNITS
whodoea such work himself or through his own employees,provided that such 1,
Improvements arc not Intended oroffered forsale.If,however,thebuilding or ! TOTAL:
Improvement bsold withlnoneyearofcomplMlon,the owner-bulWcrwlll have
tIlle�urden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT, FEE FLOOD TONE APN
u L as owner of the property,am exclusively contracting with licensed PERMITISSUANCE.
conirsdon to conatrutl the project(Ser.71M4,Bualnen and Professiona Code: .
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW kVENT-WATER(EA)
Wilds or Improves theoon,and who contracts for each pxojeab with a
cgW[+tlor(s)licensed pursuant to the Cuntradoe.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
I_f f am exempt under Sec. B 4 P C for this reawn
•
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N1'
RGCFI' X
WORKMAN COMPENSATION DECLARATION FD(TURES.PER TRAP SCHOOLTAX Y N
I hereby efflrm that I have•certificate of consent to p ,ure,ora RECEIPT M
rt ake
/eofWorrs'Campenaatlon laurana on certified co.py yththereo((Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
380QIab CJ 1 '/� RECEB'TX
Com v
Po11ryX 1 PI ly7a, _ _ GAS EA.9YSTEM-DVER4(EA) BUILDING DIVISION FEES
�en
CertiOed copy Is hereby furnished. CRGSE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
ertified copy/s filed with the city Inspection division.
CERTIFICATE OFFXEMPTION FROM WORKERS' GRFASETRAP PAID '
COMPEWSATION INSURANCE SEWER-SANITARY-STORMEA.200Rf.� Date • RCcei t#
(This section need not be completed If the permit k forone hundred dollars
($100)orless)
[ceor Is that In the performance o(the work for which this permit is WATER HEATER W/VENT/ELECTR ENERGY FEE Yleiued, —
N
I shall not employ any person In any manner iso as to become subject to the WATER SYSTEM/TREATING
Worken'Campeneatlon Laws o(Callfamta.Date PAID
Z Applicant NEW RESIDENTIAL PLMB. SQ.Fr. Date Re i t#
Z O KOTICE TO APPLICANT.If,after making this Certificate,of Exemption,you
.F should Brume subjrct to the Worknn'Compenaat[on provisions of the Labor TOTAL:
er N Code,you must forthwith comply with such provisions or this pemdtehallhn
deemed revoked. BUILDING W
O CONSTRUCTION LENDING AGENCY - SEISMIC FEE
-a -Ihereby affirm that there is a coatmctlon lending agency for the perform, ELECTRIC FEE
D Z ance of the work for which th is permit Is Issued(Sec.3897,Civ.C.) F TOTAL:
V O Lender'.Name - PLUMBING FEE
LL f Lender's Address - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W a
I nllylhat l have read thisappliatlonand rtatethattheabove Information
IL bmroct.I agree to comply with all cityand muntyordlranm and state Imus PERMITISSUANCE 31 co FEES PAID:
} relating to building construction,and hereby authorise representatives afthis - -
f' Z city to enter upon the above-mentioned property for Inspection purposes. - ALTERORADDTOMECH. Date RCCCI t#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino P
V. against llabllltk,,iadgmente,roateand expenses whkh may In anywayacorue AIR HANDLING UNIT(TO 10,"CFM) SUBTOTAL:
M
ity In consequence ofthe granting ofthls permit. -
�,II (1 ' AIR HANDLING UNir(OVER 1oMocr•M)- CONSTRUCTION TAX
ppOant/Contrado ; Data D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle havardous HEATING UNIT(TO 100,000 BTU) Dale- RCCCI t#
materlal as defined by the Cu pertion Municipal Code,Chapter 9.12,and the
Fleahhand Safety Code Sedion25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea No -
Will the applicant or(utuo building occupant use equipment or devices VENTILATION FAN(SINGLE READ) ISSUANCE DATE
which emit havrdous air contaminants as dell red by the flay Area Air I'a
Quality Management District? MOILER-COMP O11POR 100,"BTU)
4hYec �No 1�
ave read the hazy esus twterials requirements under Chapter 6.95 of, BOILER-COMP(OVER100,000 BTU) - 2 O J!1t1�
the California Floxlth k Safety Code,Sediov 25505,25533 and 25534.1 Nj F74�X
understand that if the building does not currently have a tenant,that It is myNEW RESIDENTIAL MSCI 1.' SQ.FE
.' responsibility to notify the occupant of the requlmments which must be met rj/ta P
CLI
of
prior to Issuance of a Certificate ofOccupancy. . rl V
Owner or aulhoriud agent Date TOTAL: ISSUED BY:�IJC✓KI"�" —
OFFICE,COPY