22613 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bulldin Project Identification - PERMIT NO.
io3 C,Ihds n 1, 77 22613
k4lc5� 2 �'1 -9332 CITY OF CUPERTINO-BUILDING DIVISION A
c°"1r`Name: r I03L ��`
APPLICATION / PERMIT
BUILDINGELECTRICALPLUMBINC-MECh NICAL CATEGORY CONTROL#
Amhiled/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO '
Address:
PERMITISSUANCE [:] .1:1
` •❑
LICENSED CONTRACTOR'S DECLARATION
[hereby effirentloilamlic...ad under provisions of Chapter 9(mmmenc - APPLIANCESRESIDENIAL JOBDFSCRUMON
Ingwlth Sectlon7000)ofDlvisim3 ofthe Buslnessand ProfessionsCode,and my
license le in aPa7pd rife �^ PANELS �\
License Clage L_I Lk.M ��J� _ - h
Date}Iy_ ContraRor �/
ARChall be `SDECLARATION I OVER00 AMPS
[p�+0O Zp ]understand my plata elvB 6e used ss publk records. OVER 1000 AMPS 1L ep��A N
E6 Licensed Prude SIGNSELECTRICAL I 1f��I p� l'—'
a
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC O M P A 'R'
F owingIhemrasn.(Sectlemexempt.ln.ss Contractor's License Gw fm the LVs E /a+,/ yyyyy
followingreason.(Section7031.5,Businessandr, (p ns Code:Mycity it TAME METER OR POLE INST. /
0H countywhkh requlresaperMttorotutruct,ilter,impmve,demolish,oirepair 23
A 7
any stmdupermitATE
prior to its issuance,also requires the applicant for such permit to POWER DEVICES
file a signed statement that he ie Bemsed pursuant to the provisions of the
3 w Contractor.License Law(Chapter 9(commencing with Section 7000)of Divi-
O ei.n3ofth.Budsess=dProfmiomCode)orthatheisewmptthemfmmand SWIMMING POOL ELECTRIC _VALUATION '
the basis for the alleged exemption. Any violation of Section 70312 by any I CXR
applicant for a permit subjectsthe apphcanttoa civil penalty of net name than OUTLETS-SWITCHES
SFIXT'URES ll
five hundred delta.($500). NEW RESIDENTIAL ELECIR
�n L as owner of the roe SQ• T RIES TYPE CONSTRUCTION
❑ prowillclothe perty,
a, sale(Sec.70Ktion,Businessandk,anssion,mdureh notintenaedo License Law
d foi
O dale(Sec.apply
Business property
Code:The or unproventuatior'sn
harem law
3$ does not apply to work
owner of property who n buildsorimproves thereory and OCC.GROUP RES.UNITS
whoovementss such worktInte dad of or r offered
hisowne.If,however,the provided that h
Improvements ithindnoya-lferedfmtion If, ownerbuilderwilingm TOTAL:
Improvement V sold withinoneyearo(completlorylMowner-bvdderwillhave
ten of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT
LL as owner of the property,am exclusively contracting with licensed FEE FLOOD yANE APN
p "' ISSUANCE -
contractors to ourstmet the project(See.700A Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(PAI�. builds or Improves thereon, and who contracts for such p(ojecte with a
�g0t(ador(s)licensed pursuant to the ContractoYs License Law. - FEE SUMMARY
LJ I am exempt under See B k P C for this reason BACK FLOW PROTECT.DEVICE -
'Owner Data DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N_
RECEB'T#
WORKMAN COMPENSATION DECLARATION —
FI%TURES PER TRAP SC[;OOL TAX Y— N
certificate❑I hereby affirm that I have a of consent to self-Insure,ora #
cedificateofWorke ComperuatIonlruuranmmamdiftHmpythereof(Eec. RECEIPT—
3800,1ab CGAS EA. INCA
AFEE Y N
Policy# RECEIPT N
Com any GAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
�Cer<IRed copy is hereby with
the cityed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city inspection division. '
CE TE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
'M
id
SEWER- STORM EA 2WFFT -Date Recei t#
(This sect nneed
re
complded if the permit Is for one hundred dollars
($100)
WATER HEATER W/VENT/ELECTR ENERGYFEE Y_-N
'umify ih tin eperf.".mofthewmkfmw h is is issued, —
Ishallnote any person ' ny ner sou a to ten WATER SYSTEM/TREATING -
WorkerdCore n thus Lawa (Calif. ate PAID
O Z NOTICE
NEW RESIDENTIAL FINE. Date Recei t#
Z O NO'DCE 7b ANT: er ng daeti.fka eof&empt.L.b. SQ.FL
ehoulCodc,you=a sub it the 'Co pessetion s orchis permit shall
TOTAL:
LU W deamcd you=at forthwith mmpl wit ch provisions orchis permilshallbe BUILDINGFE
� 'deemed revoked.
LU
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaf(lrmtrwhkht Li pertructlonld(dc. ag7,Clo, .I ped.mm TOTAL: ELECTRIC FEE
D Z ance.f the workfor whkh thti permit blssued(Bac.3097,C1v,C.)
00 Lenders Name - PLUMBING FEE
LL F Lender.Addrem QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imdlfythatl have read thisapplicationand datethattheabovelnformation
1rt Ismrrect.T agreeto complywith all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} W relatingtobuildingcoratruction,and hereby authorize representallvesolthis
I.. city to enter upon the ahove-mentioned property fee inspection purposes. ALTER OR ADD TO MECH.
Z
— (We)agree to save,indemnify an d keep bareness the City of Cupertino Date Recei t#
against liabilities,}.tdgerams,m&e and ezpmses which may in any wayeccree AIR HANDLING UNIT(TO 10,000 GEM) SUBTOTAL:
said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 101000 CRM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Ndure building occupant store or handle hazardous HEATING UNIT(TO 100,M0 BTU)
material as defined the Cupertino Municipal Code,Cha Chapter 9.1 Date Recei t#
b)' Ppt land the
Health and Safety code�r—S�ection 25932(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yea L�INo
Will the applicant m future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Qua lity Management District? BOILER-COMP0HP OR 100,000 BTU)
Yea ❑No
have read the h areg ..ttri.l.regdrennu is order Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the understand
to Health building Safety Code,Sectiore 25505,25533 and 25534. I
r mpoesanathatn he tifyteoccupant not threntlye
have arnmts which
that it net NEW RESIDENTIAL MECH. cJ,j.FT
prior to Baua to of a Certificate
occupant of .f the requlremenb whkh must be net (T
' prior to issuance daCertificate o(Occvpanry.
Owner or authorized agent Date {a.U�7 ss�spp �
TOTAL: ISSUED BCly �Y"
OFFICE COPY