22396 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Bulldl"g Proe I Identilkatloo I PERMIT NO.
Building Address: _. 22396
06 O)1n C
s aces A
1 b- 7)00 CITY OF CUPERTINO-BUILDING DIVISION q
I ' c°ntr(a�m."am: rngSLt" APPLICATION If PERMIT l
J_I BUILDING-E.ECTRICAT PLUMBINGMECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.
LICENSEDCONTRACTOR'S DECLARATION PERMITISSUANCE TIJ 1:1 1:1El
m
I hereby affbthat l am Bcen¢d under provisions of Chaptcr9(comment, APP11ANCES-RF9DENML L�] JOB DESCRIPTION
Ingwith Srdton7000)of Dlvlsion3ofthe Bu.uaalnessand PmfesslonsC°de,md my
effixi
lcense
LlC caro —`�dLieN PANELS
Date Corunctor 0. C:r, UP TO RIB AMPS
A C W
ARCHITECTS DECLARATION 701-1000 AMPS
aI understand my plans shag be used u public records OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
00 C0 Licensed Prolemlonal SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUEE/MLSC
F LLLLZ7777 1 herebyafBrmthatlamexempt(mmthe Contractor's LicenwLawlorthe
Mfollowing reason.(Sedion 70315,Business and Professions Code;My city or
-
PM � countywhkh requW apemnimmct,
t to rutalter,improve,denwlbhTEMP.METEROR POLE LAST.
,orrepalr i
anystrucNre prlorto its bsuance,aborequires the applicant forsuch permit to POWER.DEVICES
file a signed statement that he/s Ikeued pursuant to the provisions of the -
O k Contractor's License Law(Chapter 9(commencingwith Section 7000)of Divi-
3 O�i SWIMMING POOL ELECTRIC
s
goo 3ofthe Bushes,and Profsniov Code)or that he laexempt eherefromendVALUATION
6 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLETSSW[TCFIESFIJ(TURES
applicant fora permit subjects the applicant to a civil penalty of not mare than
live hues.ed owner
thepro NEW RESIDENTIAL ELECTR SQ.Fr. 'STORIES TYPECONSTRUCTION
�n ❑I,as iontwilldo of the property,or my employees with ween as[herr sole
mmpe c.7044,Business
work and theions Code:The
not Intended or offered for
O dile(not. pply to
oanow and fproperty Code:The or imp Roes License Taw
B does not apply torn owner ofpropertywho buildsorImprovesthereoMand - OCC.GROUP RFS.UNITS `
who
ovessuch mentsa nhimselfor edorough offehisownemployees,providedthat ildingh
Improvemenbarcdwot ithindedoroofcomplred eio then vee cider ilI have TOTAL;
improvementbwidwlthln oneycarolcompletloRtheowner-Wllderwlll have ,y.,
Uli.yurden of proving that he did not build or Improve for purpose ofule.). QTY. PLUMBING PERMIT I.* FLOOD TONE APN
❑1 as owner of the property,am exclusively contracting with licensed PERMI.I.ISSUANCE
contractors to constrod the project(Sec.7044 Business and Prof did..Code:
The Contvctor.License Law does not apply to an owner of property who PETER-DRAIN&VFM-WATER(EA)
Wilda or Improves therms,and who contracts fee such pwieca with a
ctFEE SUMMARY
cgR¢aor(a)Bansed punumtto the C°ntnctors Llmnee Law. BACK FLOW PROTECT.DEVICE -I
LI I am exempt under Sec. B k P C for this reams
OUTSIDE FITS
DRAINS FLOOR ROOF,AREA,CONED. SANITARY Y N
Owner Data BBC=N
WORKMAN COMPENSATION DECLARATION
❑I hereby affirm that I have a cerHOeste of consent to uB-Insure,ora FIXTURES.PER TRAP SCHOOLTAX Y RFGEI N NN
J x�nffiate of Workers•Comperuatios Insurance ora certified mpyth..f(Bec.
00,Lab C.) GAS F.A.SYSTEM-1 WGdOVIT.EIS PARK FFP' Y N
'38
Policy N RECEIxT N
GAS EA.SYSTEM-OVER d(EA)
Com any BUILDING DIVISION FEES
CCertified copy h heed with thhity GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
C3 Certified mpyhllled with the arty inspection dlvlslon. _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER- STORM-STORM FA.ZO®•T Date Ree"'Et"'
(this aeatlo n not be completed lithe permit bfor one hundred dollars
(51°0)oohs. WATER HEATER W/VENT/ELECTR ENERGY FEE Y N '
I rertifytti (. eperlorns °(the work for which t la tie Issued,
I hall sole any panso In manner n u t b m tic WATER SYSTEM/TREATING
Workers' tion V (GI U.Date PAID
PF NEW RESIDENTIAL PLMB.
A lido
_Z 0 NOTICETO ICA : Loft= ng chis CertBl eo Exemption,you SQFf. Date Reeel td
should become su jest to theta 'Compeasation provisions of the Labor TOTAL:
H N Code,you swat forthwith compl thmch provisions or this parcut shall be -
W D deemed revoked. - -
BUILDING FEE Z
a. G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihercbyeffirm that then b a construction lend Ing agency for the perform _ TOTAL: ELECTRIC FEE
Z anmof the workfor which this Permit is bmed(See 3097,Civ.C.) .
.o2 Lander•.Name - PLUMBING FEE
LL Lc.dce.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I mAlfythatl have read thbappilmtlanand statethatthe above information
IL is correct.I ugreeto cmmplywith all cityand countyordinances and nate laws PERMIT ISSUANCE FEES PAID:
>. N relating to building conatructlon,and hereby authorize representatives of this
z
city to enter upon the abovenxdntloned property for inspection purposes. ALTER OR ADD TO MECH. ,(We)agree to save,indemnify an d keep harmless the City of Cupertino -Date Reeei tic
V against liabilities,ladgmenb,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In con sequence of the granting of this permit CONSTRUCTION TAX
AIR HANDWNG[IMT(OVER 10,000 CPM)
Signature of Applicant/Contmd, Data EXHAUST HOOD SW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applica of orfuture bu llding occupant store or hand In hazardous HEATING UNIT(TO 100,000 BTU) Date ReCef td
material as defined by the Cupertino Municipal Code,Chapter 9.1Z•and the
Health and Safety Code Section 75537(.)7 BEATING UNIT 100,000 BTU) TOTAL:
❑Yea No
Will the applicant or tum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
I
hich emit hamrdous air contaminants as defined by the Bay Arca Air
C- Ilty Marwgement Dbtriat7 BOILER-COMP OHP OR 100,000 BTU)'
4 Ves No BOILER-COMP(OVER 100,000 BTU)
read teeth& ua Code,Srcons 25505,
b5533 and 25534.
95 of
J the R la Health building a fey Code, otcurr 7550.5,ve at sant,that I
and rata tlutlfthfythe donnIt the
hithmostit met NEW RESIDENTIAL hrEOi. �.FT. JUL T
naf Ity to notify the pot o(Ihe mpslrementawhlch must be mot \/ (eV`�_\J
pr uance of a rt111ateof0avpancy. - ���(JJ��`//.A��,aA`1rp_'
ner auth a n arca ISSUED BY:�.1(/KI,U7J7MS`�"'�
TOTAL:
OFFICE COPY