22958 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: � le 22958
e
e one: APPLICATION SUBMrFrXU A
CITY OF CUPERTINOtBUILDING DIVISION
c°"°r'jP\t64 ff'7
qN Lie'No: APPLICATION I PERMIT l ��
• .{� ///u`f !see BUILDING-¢ECTMCAI.PLUMBINGMECHAMCAL CATEGORY CONTROL N
Archit En n"r. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
HU-XJ ITTI911—VIECT17—
Address: - .. - - PERMTISSUANCE- ❑ 1:1 El
CONTRACTOR'S DECLARATION
Thereby Affimsthat l am licensed under provisions of Chapter9(commerc, APPLIANCE&RESIDENTIALCRIPTION
IngwilhSecMon7000)ofDiWsi=3oftheBuMmmandProfnsimiiCode,and my r� )OOpggg DES/BC`7 h
license is inw o dd(ed. r PANELSLic.
LIcen CoHN �l
Data Contractor azf. To 2DO ANTS
-
ARCHITECPS E LARATION XII-1000 AMPS 1�
µQ!aO xCp Licensed
un lemtand my plane slut was ed public records. OVER I ODD AMPS BQ.FC. R AREA f/SQ.
E U Llsed Professional SIGNS ELECTRICAL '
6 OWNER-BUILDER DECLARATION
G
Z. Thereby a(0rm that exempt Contractors License Law(oche SPECIALCIiCUIT/MISC
Q following reams.(Section 70315,Business and Profesakns Code:My dtyor P UTE R
Fzl"'u� c°untywhkhrequb &Mrntfom"Shutt,alter,lmpmve,demolbh,ornpalr TEMP'METT3ORPOLEINSF.
C CW y .a any structure prior to its Issuance,a ho requires the applicentforsuch permit to POWER DEVICES ^I�'y�/�1 /
P K flle a signed statement that he is licensed pursuant to the provisions of the
3u, Contndrrs License Law(Chapter 9(commendngwith Section
7000)o(Divl-
OQ slon3o(1heBusl"n,and Pm(emlons Code)arthat hekeumptthercfroma"d SWIMMING POOL¢ECIRIC _ �/ U
Qthe basis for the alleged exemption. Any violation of Sectio"7001.5 by any OU'ILESTSSWITC}� H)(TURES r( ^7 ^
applicant fora permit subjects the applicant to a civil penalty of not more than 7 L 0 (f
five hundred dollars($500). . NEW RESIDENTIAL ELECTR
❑I,a,owner of the property,or my employees with wages as their sok SQ'F-F'JFEE
TORIES TYPE CONSTRUCTION
t compensation,w0l do the work and the structure h not intended or offered for
O ule(Sec 7066,Business and Profeenk:u Code:The Contractors ldcense law
R don not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.I1Nfffi
who does suchwork himself orthrough his own employe",provided that such ,
Improvements are not Intended oroffered formic.If,however,thebuilding or TOTAL:
Improvement hsoldwithin oneyearofcompldion,theawner-bu0derwlll have
tt�,�urdeno(proving that Mdid net build or improve for purpwc of sale.). QTY. PLUMBING PERMIT .00D ZDNE APN
uu 1 as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.7044 Buslnesa ami Peofenlov Code:
The Contndor'a License Law don not apply to an owner of property,who ALTER-DRAIN&VEM-WATER(EA)
build, or Improve thereon, and who contracts for such ptojecta with• FEE SUMMARY
cgplTactor(s)licensed pursuant to the Contradoes License Law. BACK FLOW PROTECT.DEVICE
U I am exempt under See. B k P C for this maven
DRAINS FLOOR ROOF,AREA,GOND. ARY Y N
Owner Date R[CEI'1'N
WORKMAN COMPENSATION DECLARATION FIXTURES. TAK Y N
❑thereby arker that I have a l rt me of consent to sail the m or a RECD.N
31100mdlL a°(Wark<n'Compeneatlonlnsunnceoracertilledcopythereof(Esc. GAS EA.SYSTEM-1 INCA OU LETSFEE Y N3800,4bC.7 p�fPolityN ///SCy1�I�d '/ GAS EA.SYSTEM-OVER4(EA) RECEIPTa
Com anv_ rt G: BUILDING DIVISION FEES
CeniOedcopyh here tumecityfh ed. - GREASE/INDUSTRL WASTE INTERCEPTORCHECK FEE
(ikd with the city Inspection division.
CERTIFICATE OF UEMPT[ON FROM WORKERSGREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANUARY-STORM EA 41FT ate RCcei tri
Qhs section need not he completed if the permit h for one hundred dollars
(slMorlen.) WATER HEATER w/vENT/¢ECTR G FEE Y N
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of GlK erre .Date PA1
O Z Applicant NEW RESIDENTIAL PLMB.__SQ.Fr. ate RC[el 471
Z O NOTICE TO APPLICANT.-If,after making this Certificate of Exemption,you
should become subjec"o the Workers'Compensation provisions of the Labor TOTAL:
L Code,youmstforthM[hmmply MthwchpmWWmarthhpemdt ahallbe B �e
W > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY' SEISMIC FEE
I hembyaf0rm that therets a construction lending agencyfor the perforn, ELECTRIC FEE7 Z once of the workfor which this=t is Issued(S..3097,CM C.) TOTAL:
U O Larder's Name PLUMBING FEE
IL H Lend.ex Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O,W Icenlfythatlhavereadthhappllntbnand Yatethetheabovelnformation
kc°med.]agreetormeplywith all cityand county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
} 1 relating to building construction,and hereby authorize repmsentativ"of this
(_ N citytoenteru theabove-men tion edpropenyforinspedlonpurpoxa. ALTERORADDTOMECH. -�
Z (We)agree save,Indemnl(y an d keep harmless the City of Cupertino Date Recel 471
V against lkbl1 s,judgments, sand expense,which may in a"ywayaccrue AIRHANDLINCUNQ(TO10,00o CFM) SUBTOTAL:
agalnstsal ityincon fthe gra o(this permit.
AIR HANDLING UNIT(OVER lO,aOa CFM) CONSTRUCTION TAX
IgvNre o(AppOce t/Con/rector a E)(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) - Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.72,and the
I kalth and Safety Code Sml (a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes o
Will the applicant or Lure building occupant uxequipmeet ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which eMtuga xent DiRmntamlnants as defined by the Bay Area Nr -
ality Mhvgement Dl,idd7 i BOILER-COMP pHPOR iM,00(BTU)
Yea r���Os�
versa. each a Tet Code,Sect
e tIn.25ents5533 aunder nd 25534.
of BOILER-COMP(OVER 100,000 BTU)
the Gllfomia Heath Code,Senions 75505,75533 and 15536.1
understand Aha the building does not currently havealenanq that lthmy NEW RESIDENTIAL MECH. SQ.IT.
rnponslbillty ndlfy the occupant of the requirements which must be met
prlo to lx nm ofaG e ( parry
nerorauthort agent mw
TOTAL: ISSUED BY:_
OFFICE COPY