22113 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'et Id-1111caliun PERMIT NO.
"N33 22113
A A A
nn�� CITY OF CUPERTINO-BUILDING DIVISION A
m.Name: APPLICATION /PERMIT
BUILDINGFI.ECTRICALML BINGMECHANICAL CATEGORY CONTROL N
Amhilet/En n r. Lk.No:
(� QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
hLbLl
Addresn: I I' 11 y 1 4T �'�• POWTISSUANCE ❑ ❑ �jr
LICENSED CONTRACTOR'S DECLARATION �J
I hereby afforn that l am licensed under provisions of Chapter 9(comment, APPLIANCESRESIDENTIAL ]OB DESCRI'HON
Ingwith Setlon 7000)of Dlvision3ofthe Businessand ProfessitnsCbd,nd my
limosee In to deffect \T4(-/+}��yT--,, PANELSYom=
Lire seC Lic.CH NT A r lJ I�iO-,``vTL
Dal Contrado n� UP TO 2DOAM5
ARC shall
used
as
TION OVER00 AMPS
pµail Z I understand my plane ahaB be uzd ss public records. OVER 1000 AMT'S SQ.FT.FLOOR AREA E/SQ,FT.
E Z�j Licensed Professions! SIGNS EIFGTRICAL FIMLED IN
6 OWNEReBUILDER DECLARATION ��
� j Iherebyaffirm that Ism ER the DECLARATION
cen¢Law lm the SPECIALCIRCUfT/MISC
Z O '� following reason.(Section 7031,5,Business and Professions Code:Any city or
ER
0 F't9 oountywhichmqub aperMttommtrua,alter,impmve,dennlbh,orrepalr SMP'METER ORPOLE INST. �/ /1
any structure prior to its Issuance,also requires the applicant for such permit to TOWER DEVICES fE /2 1O % I
fil...igned statement that he b licensed pursuant to the proveions of the
Contractor's License Law(Chapter 9(mmenenclag with Section 7000)of Divi. SWIMMING POOL ELECTRIC ,
30 VALUATION Ift
sionlofthe Bustnessand ProlessiomCode)orthathebexem themfromand N
F 6 X the basis for the alleged exemption. Any violation of SetWn 70}15 by any OVILE'ISSWITCHESHXTURFS
applicant fora permit subjects the applicant to a civil penalty of not more than
live hundred delta.($500). NEW RESIDENTIAL ELECTRFT.
�1,as owner of t he property,or my employees wit h wages as theU sole STORIES TYPE CONSTRUCTION
�76 compensation,will do the week and the structure Is not intended or offered for
O sale(Sec.7036,Ruslneas and Professions Code:The Contractors License Law
$B does not apply to an owner of pmperty who Wilds or improves thereory and OCC.GROUP RES UNITS
whodma such work himself on through his own employees,provided that such
m
Improveents are not Intended oroffered for sale.If,however,the building or TOTAL:
Improvement is sold within oneyesrofcompltiou,the owner-Wilderwill have
t rden of proving that he did mut build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"T,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
..Fracture to construct the project(Sec.70K Business and Professions Code:
The Contractor's License Law does not apply W an owner of property who ALTER-DRAIN&VENT-WATER(FA)
Wilds or impmves therm, and whocontacts for such poojects with a FEE SUMMARY
c�WTactes(,)It...dpursuant to the Contractor's License I . BAIX FLOW PROTECT.DEVICE
ETI am exempt under Sec B &P C for this reason
Ql Ire I DF Fr IN
DRAINS FLOOR EDGE AREA,COND. SANITARY Y N
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION FIXNRE9-PER}RAI' SCHOOL TAX Y N
[]I hereby affirm that I have a certificate of consent to self-Insure,ora RECEIPT M
aAiflateof Workers'CompensationlwurancemaceAlfWmpythereof(Sec, GAS PA.SYSTEM-1 INCA OUTLETS PARKFEE Y N_
3800, S ab JREI0
Com any `SGTC GAFA.SYSTEM-0VER6(EA) BUILDINGG DIIVISION FEES
emfied copy Is hereby furnished. PLANChIHCK PEE
CemtRied copy Is filed with the city Inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20BFT. Date ReceI tF
(This section need not be complied If the permit Is for one hundred dollars
($1 EX)orless.) WATER HFATERW/VENT/Fil M ENERGYFEE Y_ N_
I artily that fu the penormance of the work forwNch this panni!Is blued,
I shall not employ any person In any manner m as to become subject to theWATf71 SYSTEM/TREATING
Workers'Compensation Taws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.F. Date Remi ted
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compereation provisions of the Labor TOTAL:
F' N most Code,you ostforthwith comply with such provisions or this permit shall he BUILDING FEE
W > demand revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I lumbyaffirmthat there Is a construction lending agency for the peiform- ELECTRIC FEE
Z ance ofthe work for which this permit bieseed(Sec.3097,CIv.C.) TOTAL:
U O Iandera Name PLUMBING FEE
LL r Lerder.Addecsa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE -C1�
OW leertifythatl have read this application and Asia thatthe above information
1 Ismnet.l agree to comply with all city and county mdlnancesand state laws PERMITISSUANCE FEES PAID:
relating to building construction,and hereby authorira repece,mativesof this
F N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cu penino Date Receipt#
V against liabilities,judgm ants,costs and expenses which may In any way same AIR HANDLING UNIT CIO 10,000 CFM) SUBTOTAL:
g said City In run,epyc oftgam*" of hb Permit'/_' CONSTRUCTION TAX
�� IQ�I AIR HANDLING UNTT(OVER 10,000 CFM)
.i re of Applicant/Contractor 3 ate IXELAUS'I}IOOD(W/DUCT) CONSTRUCTION TAX PAID:
cam/ HAZARDOUS MAT LSDIS 5 E
Will the applicant or future building occupant store or handle hardou, - HEATING UNIT(TO 100,000BM Te Date Recel tit
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Ilalth and Safety Cade Section 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ya
Will the applicant orfuture building occupant use equipment or devices VENITLATTON FAN(SINGLE RESID) ISSUANCE DATE
which emit haeard..air contarometa as defined by the Bay Area Ab
Quality Management District?
PFI'Oft l00,IX0 BTU)
❑yes10 No
I have read the bazar7i mus materials requirements under Chapter 6.95 of MOILER-COMP(OVER 100,000 BTU)
the Calif=Health&SafetyCode,Sections 25505,25533 and 25533.1 � � P
understand that if the building does not currently have a tenant,that it my NEW RESIDENTIAL MECH. SQ.FI AN , �9
a
responsibility to nalfy the occupant of the requirements which most be nstt
prior to entente of a Certificate of Ompancy. `` ''
Owner or authorised agent Date TOTAL: - ISSUED BN
OFFICE COPY