22491 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building PreisCI Identification PERhllT NO.
Building Address: 99 /1/o�rs/a/Esi ..rQd00?z-: 22491
6. o e: A
CITY OF CUPERTINOLBUILDING DIVISION
Contra oI/a�y�e _ auf�y:� APPLICATION /PERMIT
/ e-� /Uf�e ``11 ], BUTLDINGELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL N
qW Architect/Engineer: Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PEtMITISSUANCE ❑ ❑ E]LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(comment, APPLIANCESRF.SIDENTIAL JOB DFSCRB'TION
Ing with 5ectb affect. oflhe Business and PmlesslonsCode,asci my
license Is In "fo doffer. Q PANELS
Gpruz
LlcenscChss Lk.p 0
Date Contractor UP p1 2WAMPS
ARCHITE AT OVERIUBBAMPS SQ.FT.FLOOR AREA $/SQ.FT.
�q+0CC7O Iundemm�d my pisco dull be used epubllcreen w
ice Z U
Licensed Professional SIGNSELECTRICAL PMA
I N
G tu OWNER-BUILDER DECLARATION 7—E OBL 0�
[r, 3 SPECIAL CIRCUIT/MIST
7t„ owingrcum. tlutlamexemp fronts and
Proltor'allodse law fort he
OO followingreason.(SectionrmittoBusinessandr,ImprbmCade:Mycityir V1 P TER
O Z F. TIME.METER OR POLE INST.
P� any stywhichpdortoss hatuantocoo requiesthe aprovntforsch,ormit to
any at rucWretatemeto lUhathe p also rersuant to the forauchpeof to ppWFR DEVICES
a U Co a signed statement that he b r9(tom pursuant to the proWiam of the
Contractors LicensesandLaw( fetWm CWe)orthng with Section 70100)erefof Divi- SWIMMING POOL ELECTRIC ON
F O..:J7J7 slon3of the 8uslnesand ProfcekraCde)orthat hebexempl therefromand
6 5 the basis for the alleged exemption. Any violation of Section 7WIS by any OUTLETSSWITCHFSEXTURES
applicant for a permit subjects the applicant to a civil penalty of not mare than
five hundred dollars(SSW). NEW RESIDENTIAL RLECTR SQ. STORIES TYPECON51RUCTION
.. n I,as ownat of the property,or my employee with wages as their sole
C compensation,will do the work and the structure is not intended or offered for
'S p sols(Sec.70K Business and Professions Code:The Contractors License law
7$B duxes not apply to an owner of property who builds or improve thereon,and OCC.GROUP RES.UNITS
E whodoessuchworkhimselforthrough hisownemplayess,provided that such
Improvements are not ntended orofferd for sale.Khowaver,thebuildinger r A
Improvement III withinoneyearofec mpletion,the owner-bu8derwlll have
thc*I,rden of proving that he did not build orimprove for purpose Music.). QTY. PLUMBING PER I FEE FLOOD ZONE APN
Lj as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(See.70K Business and Prefesslore Code:
The Contractors License law does not apply to an owner of property who — ALTER-DRAIN&VFNrI'- (EA)
Wilds or improve thereon,and who contracts ach for eprojects with a FEE SUMMARY
,,BB11((atoKs)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.D CE
LII am exempt under Sec B &P C for this reason
DRAINF.FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• Owner Data RECEBT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
�f♦•iereby affirm that 1 have a certlRcate of consent to ulGlnaurc,ora RECm•I'N
certificate of Workers Compensation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-]INCA OUTLETS PARK FTE Y N
3800'I.b C.) / / D / S3 0
Policy p RECEIPT N
Co any GAS EA.SYSTEM-OVER 4(EA) BUILDING D I VIS ION FE ES
miffed copy is ha.5y fumi ed. GREASEANDUSTRL WASTE INfFRCEPTOR PLANCHECK FEE
Candied copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA AOFT Date Recti t#
(fhb section ned not be completed lithe permit b for one hundred dollars
($100)or less.) WATER HEATER W/VENT/E.ECTR ENERGY FEE Y_ N_
1 certify that In the performance of thewwk forwhich this Permit b issued,
1 shall not employ any person to any manner so as to become subject to the WATER SYSTEM/TREATING PAID
WorkersCompensation Laws of California. Date
TICE TO APPLICAIf,after nuking this Certificate of Exemption,you NEW RESIDENTIAL PCMB. SQ. . Date Recel t#
licant
Z Z NONT:
should become subject to the Workers Compensation provisions of the Labor TOTAL:
CC CC y Code,you must forthwith comply with such provbloro or this permit shall be
BUILDING FEE
W > deenrd revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL O I hereby affirm that there is a e otmetion lending agency for the perform TOTAL. ELECTRIC FEE
Z anre of the workfor which this permit fs isud(Sec.3097,Civ.C3
(� O I<ndere Name PLUMBING FEE
U. H Leder.Address QTY. MECHANICAL PERMIT IEE MECHANICAL PLG
OW Imnrfythatlhavemadthbappbutbnarulstatethattheabove Nfor ion
a is comet.I agree to comply with all city and county ordinances and gate laws PERMIT ISSUANCE FEES PAID:
>. relating tobuliding construction,and hereby authorize representatives of this
F U) city to er upon the Axwe lord property for inspection purposes. ALTERORADDIOMECH.
(W to save,indemnify as d keep harmless the City of Cupertino Date Receipt#
V agalnt0 I Ie,jrdig eta, n cad ex a which may in any way accrue AIR HANDLING UNIT CTO IQ000 CFM) SUBTOTAL:
agar fry in con the n of this permit.
_:Jam/ AIR HANDLING UNIT(OVER IO,000CI11) CONSTRUCTION TAX
Fl
SI reof p cant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAlARDOUS MATE LS DISCLOSURE
Will /Meant or future building occupant store or handle hazardous HEATING UNIT(TO 100,"BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
I kalth and Safety Cde Section 25537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: l
M Yes M No
Willthcapplicant or future building occupant use equipment ordevias VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay,Arca Air Ad,�
Quality Management District? BOILER-COMP(3}ff'OR ItXI,O(q BTU) jr�+ft
El Yes FF�II No
have read the h azarr ous materials requirements u nder Cha p(er 6.95 of BOILER-COMP(OVER 100,000 BTU) �``II` +
the California Health&Safety Code,Sections 15505,75533 and 75534. 1 1A /
p
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. Fr e
responsibility to notify the occupant of the requirements which at be met
prior to go.nee ofa Certificate of Occupancy,
Ownerorauthtelmdagent Date TOTAL: _!ISSUED BYM =f(
OFFICE COPY