22526 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
!Lildins Proiect Identification
uildingA drew:
PERMIT NO.
22526
one:
CITY OF CUPERTINO- BUILDING .DIVISION
APPLICATION /PERMIT
BUILDING-fl,CTRICAL-PLUMBING-MECHANICAL r
E
p
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c ray vane: �'/}y�'
/i Nm
CATEGORY
CONTROL N
hltelt/Engineer. Lk. Na
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
PERh9TISSUANCE
FEE
❑ 1:1❑
LICENSED CONTRACTOR'S DECLARATION
Ihercbydftr thatlamlkcosedunderp.Wonsof Chapter9(..m
ingwith Sact(iyooLBn��7000)of rAvlsion3ofthe Buslnenand PmfessionsCode, and my
Lice, iClasL` LicdeffeN ! G
Date.5 /;3t � Contra la0or
APPLIANCESRESIDENTIAL
JOB DFSC711
1
V ewe
PANELS -
201-1000AMPS
ARCHITEC'TSDECLARATION
I undeistand my playshall be used as public record.
Licensed professional
.ILnJ
OVER1000AMP5SQ.
FT. FLOOR AR
S/SQ. FT.
SIGNSELECTRICAL'
SPECIALCIRCNT/MLSC
OWNER -BUILDER DECLARATION
I herebyaffimnthm
atl aexempt fromthe ContractLl
or'smns, Lawfwthe
I
P..0 T R
TEMP.M171RORPOLEINST.
following reason. (Section 7031.5, Business and Professions Code: Any city or
countywhichsuch,poermit
requprior
/�• �/
teapermittocoo,requ,eller, pp nntfor
any atructure pater ent that ee6licensed pursuan Rthe pro isio matte
to
file a aigned statement that he pursuant it the providers the
POWER DEVICES DATE
_
SWIMMING IDOL ELECTRIC
t v9(com f ivi-
a, 3ofthe License law(rofessmr9(commencing with Section7000).f Divi-
sion3ofthe Business and Profeselora Code)orthat he isexempt therefrbmand
a,
VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicant fora permit subjects the applicant to a civil pemlty of not more than
OUTLETS-SWTTCHESFIXTURES -
-
NEW RESIDENTIAL ELECTR SQtT'
five hundred dollars(5SM. -
❑1, as owner of the property, or my employees with wages as their sok
STORIES
TYPE CONSTRUCTION
compensation, willdothe work andthestrocture h not Intended or offend for
sale (Sec. 7094, Business and'Profesdora Code: The Contractors Limme Law
docs not apply to an owner a property who builds or improves thereon,and
who donsuch work himselforthroigh hlsown employees, provided that such
.00C. GROUT'
RES. UNITS
improvements are not intended oroffered fmrxle. If, however, the building cr
TOTAL:
Improvement bsold withinoneycarofcompletion,the owner-bullderwlll have
QTy, PLUMBING PERMIT FEE
tI(p*dan of proving that he did not build or improve for purpose of sale.).
Lf I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sen. 7/94. Business and I'mrassoms Code:
FLOOD TONE
APN
PERMIT ISSUANCE
a� d
The Contractor's License Law don net apply to an owner of property who
builds or imprmvn therein, and who contracts for such pm lojewith a
o�R(�+cou(s) licensed pursuant to the Contractor's License Law.
Lf I am exempt under Sec. B 6 P C for this reasomOUTSIDE
ALTER-DRAINk VENT -WATER (EA)
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
FEES
DRAINS- FLOOR ROOF, AREA, COND.
Fp(NRES PER TRAP
SANITARY Y N_
RECEIPT a
Owner Data -
WORKMAN COMPENSATION DECLARATION
❑I hereby afflrm that I have a certificate of consent to self-insum, or a.
certificate ofWurkere Comperuatlon Ira a certified ropy themof(Sec.
3800. Yb CJ Z
��eL A
SCHOOL TAX Y_ N
RECE F N
GAS FA. IT INC.40UTLEfS
PARK FEE Y N —
RECEIPT N
S F.A.
GASYSTEM-OVER4(CA)
y
ComY....-
BUILDING D I VISION FE ES
1lCenifiedropyishembyfu iah� �
Ccmfied copy is filed with the city inspection division.
GREASE/INDUSIRL WASTE INTERCEPTOR
PLANCHECK FEE
GREASE TRAP
CERTIFICATE OF EXEMI'TION FROM WORKERS'
PAID
COMPENSATION INSURANCE
(ThlssecUon need nct ba completed Ithe perddt h forone hundred dollars
SEWER SANITARY STORM EA 200F7 tl
S
Date RLYCI 1#
WATER HEATER W/VENT/ELECTR
ENERGY PEE Y - N
'
($100) or less.)
I unify that In the performance of thework for which this permit Is h turd,
WATER SYSTEM/TREATIN'G
I shall not employ any person in any manner so as to become subject to the
Workers' Compensation Laws of California. Date
PAID
AI D
NEW RESTDENTIALPLMB. SQFG
Applicant - -
Dale' Recei t#
NOTICE TO APPLICANT: If, after making this Certificate o(Exemption, you
should become subject to the Workers'Compenuation provisions of the Labor
..
TOTAL:
/
BU IN "E
Code you =at foe hwith comply with such proWlons or this permit shall be
deemed revoked.
CONSTRUCTION LENDING AGENCY
SEISMIC FEE
Iherebyaffirrethat there is a coramuction lending agency forthe performL:
ance of the work for which this permit e, Issued (Sec. 3097, Civ -G
Lender's Name
Lender'sAdd '.
I certify thatl have read thhappbotionand state thatthc above infomutlon
hcorrect. I agree to complywith all city and county ordinances and state laws
'j
TOTAQ, dO
ELECTRIC FEE
PLUMBING FEE
Y0.66
QTY. MECHANICAL PERMIT FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
relating to building construction, and hereby authorize representatives of this
'
city to enter upon the above.mentkmed property for inspection purpose.
(We) agree to save, indemmify an d keep harmless the City of Cupertino
against liabilities, judgments, cossand expenses which may in anywayaccrue
ALTERORADDTOMECH.
Date Receipt#
AIR HANDLING UNIT CFO IO,ODOCFM)
SUBTOTAL:
ago said City conxquenceofthegrantingofthispermlt.
a
AIRHANDLINGUNTTrovER ]0,100CFM)
-
CONSTRUCTION TAX
'Whaftibe of Applicant/Contractor Date
IXHAUST HOOD (W/DIK:T)
CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
HEATING UNIT CFO 100,000 BTU) -
Date Recei t#
Will the applicant or future building occupant store or handle hazardous
material as defined by the Cupertino Municipal Cade, Chapter 9.1 2, and the
I InIth and Safety Code Section 25532(a)?
❑ Yes NN.
I [EATING UNIT (OVER 100,000 BTU)
TOTAL:
O , O
VENTILATION FAN (SINGLE RFSID)
IS$UA4j DATE
Willtheappllant orf wt bcildingomupantuseequlpmentordevlccs.
which emit harardoa air contaminants as defined by the Bay Area Air,
Quality Management Dia❑lect? -
4have read the hazards aomaterials requirements under Chapter 6.95 o("
SEP 1 -1 1991'
BOILER -COMP OHPOR 100,000 BTU)
BOILER -COMP 100,(X0 BTU)
the Califomla Health k Safety Code, Sections25505, 25533 and 25534. 1
understand that if the building does not currently have a tenant, that it Is my
NEW REST DENTIAL MECH. SQ.FT
respommet to notify the occupant of the requirements which must be et
prioFtoieuancedacertifiateof Occupancy.
.
City of Noer{'Ro
�i 1l
ISSIIEDBY: 1,a # 1 tjuc
Owner or authorlud agent Date
TOTAL:
OFFICE COPY