22056 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project IdentIflotlon 7777 PERMIT NO.
Bulletin Adorns; 1 - 22056_
CITY OF CUPERTTN0.BUILDING DIVISION
APPLICATION I PERMIT )
BLULDING-ELECTRICALPLUMBING.MFCHAMCAL CATEGORY CONTROL M
Architect/Engineer. Lk.No:
�1 QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: I SS �Lr
PERMIT ISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
MthSy on7Otlutlam Licensed under dPm Chspte C9 e,and APPLIANCES-RESIDENTIAL JOB DFSCRR'770N
inenseISectlon7fX10)of DlWsl°n3o�l�t-+{�e(B�uelneaand Pro(nelonsCade,and my
license le In fuBr}MXpg yid d(ect. 1 C�/ PANELS
License CLrr�C,�J�Ic.M I '("'✓���0 ��Y'C]\T"r�gL
DateUP TO 2DOAHM
IC HITT or_
ARCHITECTS E RATION OVER
AMPS
DO Iundcntand my pias shall be used apubllc records. OVER 1(X10 AMPS SQ.FT.FLOOR AREA f/SQ.FT,
o Licensed Professional SIGNSELFCTRICAL m N1 .1 E D I N
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MLSC
��jj Them affirm thatlamexem fromthe Contractor's Lianw LAwforthe
0 2:3 6q following reason.(Secllon 70315,Business and Prefessione Code:Any city or TEMP.ME ILROR POLE INST. a P 1 R l
P t'�{ t ntywhlrhnqulreeapermlttomrutr Mg ter,Impmve,de.tWh,ormpalr ET
fig❑ nystrueture pdorto itslseuance,also requlrestheapplinnt(orsuch permit to ���®/�
a ]OWER DEVICES
O�+ V file a signed statement that he t Licensed pursuant it the tionprovisions of theDATE
3µ(.
soma
o sof the Llcenselaw roffmaer9(commcncing eIsexe ptthe0)of Divl- SWIMMING POOL ELECTRIC VALUATION
elon3o(theBuelnnsand ProfemloaCode)arthat hebexemptthee(romand
O....53333 the basis for the alleged exemption. Any violation of Secllon 70115 by any OUTLETv-SMTCHF4FIXTURFS
applinnt Ima pertrdt,ubjects the applicant to a civil penalty of no more than
E $ flue hundmd dollars(5500).
I, sawr�er of the NEW RESIDENTIAL ELECTR SQ.PT. STORIES TYPE CONSTRUCTION
�n prop lt,and my employenmInten ed as offered
fo
compensation, hudeslhework,end lhestruciure Vnotintendedo License Law� O sale(Sec.70/4,Bueimaa and Prolembns Code The Contractors License Lew
$ don not apply to an ownerof propertywho bulidsor improvntheeon,and OCC.GROUP RFS.UNITS
whodera suchwmichimseB orthrough hisownemployees,provided that such
m
improveents are not Intended om(fered for sale.IL however thebuildlag or TOTAL:
Improvement(sw41 withinoneyearofmmpinion,theowner-builderwill have
tlifi-Jgud'n of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
LLJJ L s owner of the property,am exclusively contracting with licensed PERMIT ISSUANCEcomracton,to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law clan not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wre
ilds or imp.thereon, and who contracts for such pt° - -
jects with a FEE SUMMARY
c�traeor(s)licensed pursuant to the Contvetor'sLicense Law. BAIX FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B Is P C for this reason
IEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date BBC=N
WORKMAN COMPENSATION DECLARATION FD0URF_e.PER TRAP SCHOOL TAX Y N
hereby affirm that I have a imu.a is o!consent m py insure,ors RECEIPT s
40 ce I(Irate ofWorkem'C°mpewatlon lruurance ora certi(led copythemo((Sec. GAS G.SYSITM-1 INCAOUTLRTS PARKED: Y N
3800.LbCah7 As'J'/1rp�� A RECEIPT It
I'o11ryM llL �F �"l I V GAS G.SYSTEM-OVER 4(G)
Companv�(� BUILDING DI VISION ITE!
�Cerfied copy's filed
thehM. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�y
Certified copy b(fled with the city inspection division.
CERTIFICATE OF E)tEMPFION FROM WORKERS' GRGSETRAP PAID
COMPENSATION INSURANCE SEWE&SANITARY-STORM EA.MET.
DteaRCtel t#
(Thlssectlon need not be completed if the permit is forone hundred dollars
(f10(Borless.) I
WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certifythat In the performance of thework forwhich this permit is lxued,
I shall not employ any Penson in any manner so a/o become subject to the WATER SYSTEM/TRGTINC
Worken'Compenation Laws°f GllfomU.Date PAID
licant
Z 0 NOTTCF TO APPLICANT:If,after making this CoMfcaieol Exemption,you NEW RESIDENTIAL PLMB._SQFF. Date RL'rni t#
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Coils,you=at forthwith comply with such provisions orthis permit shall be
W EE
> deemre
ed voked. '
CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL lhembyaf0rm that there is a construction lendingagenry forthe perform ELECTRIC FEE
MO anceo(thework forwhleh this permit b Issued(See,3097,CIv.C.) TOTAL:
Lender's Name PLUMBING FEE
LL F Lender's Addreea QTY. MECHANICAL PERMIT FEE
O W Indilylhat l have mad this applicationand statethatthe aboveh"omuIlan MECHANICAL FEE
1 Ism rect,lagreelu complywilh all city and county ordlnanrea and Atelawe PERMITISSUANCE ' QU FEES PAID:
>. U) relating to building conslrucilon,and hereby inaluelac reprexenlalivnof this
H Z city to enter upon the above-menlbned property for lrupMlan purposes. ALTER OR ADDTO MECH.
V — (We)agree to save,Indemnify an d keep harmless the CI of Cope rt Ino Date Recel t#
against liabilities,judgments,costs and expenan which mal) saywayamrus AIR HANDLING UNIT ITO 10,000CrM) SUBTOTAL'
agat Inmnsequenceofthegrantingo(lhlaS.� t AIR HANDLING UNIT(OVER 10,(100 CFM) CONSTRUCTION TAX
Sfixeffule of Applicant/Contractor Date IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 'a-JI
Wllltheappllont ortutum Wilding oaupantstore or handle haaardous HEATING UNIT(TO 100,ODO BTU) eVv Date Recef t#
material a defined by the Cupertino Municipal Code,Chapter9,1Z and the
lic.1t Yaened SafetyCode,Sento 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: L
Will the a pplieset or❑future building occupant use equipment or d evices VEMIGTION FAN(SINGLE RESID) IS$}JAI)JGR,DATE
which emit hsardous air contaminants as defined by the Bay Area Air 'a-lTg,(jatl+_aG1'
Quality Management District? BOILER-COMP DEI'OR 100,000 BTU) yp
4 Yes RNo MAY 'Y �,
havnread Health
ar ous materialsectionrementsundcrChapter.1 of BORER CbMP(OVOt 103,000 BTU) 8
the Californiaat lith building
Cade,Sections75505,ve a tenant,
understand that lithe the occupant ofnot herequohavea tenan4 that b bey NEW RESIDENTIAL MECFI. SQ.PT.
responsibility ce notify the occupantofthe requlmrrenlawhich mustWmet
prior to issuance of a Certlfinte o(Occupanry.
Owner or authorised agent DateISSUED BY:
C)TAL:
OFFICE COPY