21988 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY BUILDING ELEL A PERMIT ND
BUIJCUPRTIAPPLICATION/PERMIT PLUMBING-MECHANICAL
1 BUILDING PROJECT IDENTIFICATION
23
„O O
UILDING'ALIEESS: I ►�s. ` SANITARY NO. APPLICATIONS .FTTTALDATE
UNITa LOT#
OWN RSNAME: PHONE: C ACTOR'S NAME: LIC NO:
RCNon N/C CO OL#
RC iITECf/ENGINEER: LIC NO:. - KESS: 1 ❑
CONTACT: PHONE: QTY. ELECTRIC PERMIT FEE BUILDING PERMIT INFO
BLDG ELECT PLUMB NIECE
PERMIT ISSUANCE �� El El
LICENSED CONTRACTOR'S DECLARATION APPLIANCES-RESIDENTIAL OB DESCRIPTION
miaiz Ihereby affirm thatlamlifirell underprovisionsof Cha d (d licenavism
W,�00F Sell ifto lf10()of Division 3 of she Business a d Pmfeesiona Code,and my license is in PANELS
full force and effect. Q - Up T0200 AMPS vJ
Licen I C1 Llc.#
tFis z)"o pale Con[ 201-1000 AMPS
ZOIDir� 1sta -ARCHIbeuse OVER 1000 AMPS SQ.IT,FLOOR AREA ^. S/SQ.FT.
O Z'—❑ undernd mys s
planhall a cords.
SIGNS ELECTRICAL
Licensed Pro&sslonal
y
OWNER-BUILDER from DECLARATION ON SPECIAL CIRCUIT/MISC.
p(O'i F d hereby affirm That I am exempt from the Cessions Co License Law for @e '
W 3 O ti¢ following reason(Section construct,
Rosiness and Professions Coda Any city a county TIME.METER OR POLE INST.
�1 rn M which requires a permit to rnnsweq alma nt forsta demolish,nr repair any tamcture
`ZY� pat Imississueacealso urscuret to the
theapplicantCotractosfilease La statement POWER DEVICES
W ps than be is licensed pursuant to the provisions of the Contractor's and Pre Lew(Chapter
'4• e{t, 9(cammeis(commencingwith
therefrom
andthe brousior 3ofshe Business and Professions Craft) SWIMMING POOL ELECTRIC VALUATION
orthatheisexempnherefroma[for a permit
ects thedexemant to civiny l
of
h.Za Section'/03LS by any applicant for pertnil subjects she applicant ecivil penalty of OUTLETS-SWITCHES-FIXTURES �• �`/'yp1�
u❑$p tmore manfvehuadred dolirea(E500). NEW RESIDENTIAL ELECIR —SQ.FT.
n❑ I,asownerofthepmpay.ormyemployceswimwagesastheirsolecompensation, STORIES TYPE CONSTRUCTION
p, we will Bothe work,and the smartimi.nminmadedoroffcmdforsale(Sm.7044.11tomess ^,
and Professions Cade:The Contractor's License Law does not apply m an owner of K„ Wlt
property who builds or improves thereon,sndwhodoesauchwork himselforthrough his
ownemployees,provided Natsuchimprovementsarenotintendedmofferedforsale.If, OCC.GROUP RES.UNITS
however,the building Or improvement is sold within one year ofcampletion,the owner-
builder will have the burden of proving that he did not build or improve far purpose of
sale.).
❑ I,asownerofthepropeny,amexclusivelycontractingwishiicensed.owacro..to QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
consumer the project(Sec.7044.Business and Professions Codes)The Contractors
License Law does not apply to an owner of property who builds or improves thereon,and PERMIT ISSUANCE
who contracts for such projects with a contractor(s)licensed pursuautto the Contractors ALTER (EA)License Law. ) FEESUMMARY
❑ 1 am exempt under Sea B&P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
SANITARY Y N
Owner Date DRAINS-MOOR,BOOPAREACOND. RECEIPT#
WORKMAN COMPENSATION DECLARATION , , SCHOOLTAX Y N
EI hereby affirm that l have a cendfcase ofmasent to self-insure,or a certificate of RECEIPT#
Workers'Com,surarion Insurance or acenified copy thereof(Ses.3800,Lab C.)which FlXTURES-PER TRAP PARK FEE Y N
covers all employee's under his permit. GAS-EA.SYSTEM-I INC.4 OUTLETS RECEIPT#
Policy is BUILDING DIVISION FEES
Company GAS-EA.SYSTEM-OVER 4(FA) PLANCHECK FEE
❑ Certified copy is hereby furnished.
❑ Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR GRADING FEE
I CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
'1'1 COMPENSATION INSURANCE
(Thissection neednot be completed ifthe permit ismame,hundreidollers D I00) SEWER-SANITARY-STORM EA.200F7. ENERGY FEE
�• 1 modify that in In/ once of she work for which this efmiI is is sued,Ishall WATER HEATER W/VENT/ELECTR
not employ u F(in n n nnef s o o net to,the Workers' PAID
Comps 'alifon a Dete WATER SYSTEM/fRFATING Dam Receipt#
z Appll , + ✓
I NOTICE aw T:If,after making this Certificate of Exemption,you should NEW RESIDENTIAL PLMB. SQ,FT. TOTAL:
V) become subjeett e Workers Compensation provisions of she Labor Code,you must
�i , forthwith comply with such provisions or this permit shall be deemed revoked. BUILDING FEE
�WCONSTRUCTION LENDING AGENCY SEISMIC
M FEE
5 I hereby affirm that hem is a construction lending agency for the performance of TOTAL: ELECTRIC PEE
U O the work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name 19
~F Lender's Address QTY. MECHANICAL P MIT FE PLUMBING FEE
U 1 certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating to PERMIT ISSUANCE MECHANICAL FEE
ybuilding construction,and hereby authorize representatives of this city to enter upon the CONSTRUCTION TAX
fJ 7 above-mentioned propcny for inspection purposes. ALTER OR ADD TO CH.
A (We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilities,judgmens,costs and expenses which may in my way accrue against said City AIR HANDLINGIT TO IO,IXq CP
in consequence of the granting of this permit. ,
m 1 AIRHANDL GUNIT(OVEWI MkOdA)
Signature of A,diewn/Contommr Dam EXHAU HOODOVDUCT)
PAID
HAZARDOUS MATERIALS DISCLOSURE HEATT UNIT(TO 1 W / Date Receipt It
Will the upplicaut or future building occupant score or handle hazardous material HEATINGU (OVER) BTU) T
ss defined by dm Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532001 VENTILATION (SINGLE ID)
❑Yes No ¢¢bb
TE
Will th1,pplicmtorcontaminants
im building by the
equipmentQualit Management
BOILER-COME(3H OR 100,000 BTU) g— �SUAIIJ A
azone? yr cantaminanse ea defined by she Bay Area Air Quality Management BOILER-COME(OVER 00,000 BTU) SEP = .9
iam o SEP
❑Yes No NEWRESIDENT MEC SQ.FT. 199
I have read the hazardo s;materials requirements under Chepmr 6.95 of she. G�IY_Uf
Culifomia He A,Safety Code,Sections 25505,25533 and 25534. I understand that _-_ 1-urtK l lnV
if the buildin concurrently a tenant,that is is my responsibility to notify the -
req encs w is must be met prior to issuance of a Cetuficam of
nen an 4 �'
Ow zed agent Date TOTAL: ISSUED BY:�
OFFICE