22026 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bu aft Pro eel IdentificationPERMIT NO.
Building Add to.: 11 ,12. - •I ', 1 rMr's nA - 22026
n,(8 arh: rte:
5'6 $7l CITY OF CUPERTINO-BUILDING DIVISION
1�
Contotelm'c N. Lm.Ne: APPLICATION /PERMIT 6 l
BURDING-ELECTRICALPLUMBING-MECFI LAICAL CATEGORY CONTROL M
ArchitM/Engineer. � Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACFOR'S DECLARATION
I herebyon7OO)ofI odChsincofordowne. APPLIANCESRESIDENTIAL JOB DFSCRITION
Incense I.I t ail 7000).14 die.. 15,eBuelneuandProfe�elone Code,and my
license lsi'(uB` and dies. C PANELS
Lirense ass I LICM J_c �.m
Date Contactor
ARCHITECPS DECURATID 701-IMOAMPS
%Z ]understand my III...hall be acted as public records. - OVER IOW AMPS SQ.FT.FLOOR AREA $/SQ.FT.
O
Licensed Professional SIGNS ELECTRICAL
6 OWLARATIONNER-BUILDER DEC
1'n a SPECIALCIRCUIT/MLSC
7 F."✓ owing reason.
l am 31.5,Bxempt sines e C Proles o Lirenm law for city or
qqqq following reason.(Section 7031.5,Business and Professions Code:Any city it
F k'q countywhich requiresa permit to coratrot,altep improve,demolish,orrepalr TEMP.METER OR POLE]NST.
`a 3 anystmmm pdortolts Issuance,also requlreatheappllant torso&permit to
(� file a signed statement that he is licensed pursnt tre
uao the preelsloof the POWER DEVICES
30fn Cmdracim'e License Law(Chapter 9(commencing with Section 7000)of Dlvi- SWIMMING POOL ELECTRIC
sion 3 of the Businmand PnefessloraCode).,the he isexempt therefromand VALUATION
E5 G the balls for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS SWITCHFSFI%TURES
applicant fora permit subjecla the applicant to a civil penalty Meat morethan
five hundred dollars($.500). NEW RISIDENTIAL ELECTA
�n ❑7,as owner of the property,or my employees with wages as their sole —�'�' STORIES 7YI'E CONSTRUCTION
compensation,wlll dothe work,and thestruRum is net intended or offered for
O saleCSee 7614,Business and Professional Code:The Contretoe.License law
S� does not apply to an owner of property who builds or improve&thereon,and OCC.GROUT' RFS.UNITS
whodoasuchworkhb lforthraughbisownemployees,providedthatsuch
improvemrntsarenotlnlendedoroffBredforeale.l(howevegthebulidingor - TOTAL:
improvement Itself withinoneyearofcomple lon,theowner-builderwill have
to rdenol pmvingthd he did rhos Iulldorlm,cov.1o,purpomol sale,,, QTy. PLUMBING PERMIT FEE FLOOD ZONE MIN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to coretrot the project(See,7WBuslness and Professim s Code:
The Contractor's License Law does not apply to an owner M property who
buALTER DRAIN&VENT WATER(EA)
Willa or improves thereon,and who comrade for such projects with a
cgat(ator(s)Bernard pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE SUMMARY
I_J I am exempt under See B &P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner-- Date RECEIPT
� WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI{s70L TA% Y N
�1pe reby affirm that I have•rertifiate of consent to self-insure,or a RECEIIT N
cerIIflateof Workers'Compemationlmuranmo acedlfk wpythemof(Sec' GAS EA. INCA OUTLETS
33W,IAb C.) PARK FEE Y N
Policy M RECEIPT 0
Com CanY GAS EA.SYSTEM-OVER 4(EA)
BUILDING DIVISION FEES
edified copy is hereby famished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
�Certlfied copy 6 filed with the city Irapoolen division.
CERTIFICATE OF E%EMPFION FROM WORKERS' GREASE TRAP PAID ,L
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 2WFT Date Recei t# 4.35
(Thls.etlon need not be completed If the permit isfor one hundred dollars
(s100)mlen) WATER HEATER W/VENT/FLFCTR ENERGY PEE Y N
I cenlfythat in the performance of thework forwhich this permit is issued, —
I shall not employ any person in any manner so as to become subject to the WATQ{SYSIEM/TREATING
Workers'Compensation Laws of California. Date PAID
0 Z Appllant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTUL PLMB, SQ.FT. Date Recel t#
Fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
y Code,you must forthwith comply with such provisional orthis permit shall be U IN 'E l�
j *deemed revalued.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a cmwtrutlon lending agency for the perform- ELECTRIC FEE
:) Z an..(the work for which this pe rmitisideed(See.3097,CN.C.) TOTAL:
0 O Finder's N.me PLUMBING FEE
IL F Lende,.Address QrY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedlfythatl have read thisappllationand slatethatthe above Information
4 lordet.l agree to comply with all city and county ordinances and tate laws PERMITISSUANCE FEES PAID:
W relating to building construction,and hereby authorlu representatives of this
Z city to enter upon the above-mentimand property for lnspedUm put rposes. ALTER OR ADDTOMECH. Date RfCel [#
V — (We)agree to save,indemnlfy an d keep harmless the City of Cu ped Ino P
against la ltla,pdgmenb, end expenses which may In anywayaceroe AIR HANDLING UNIT(170 IO,ODOCPM) SUBTOTAL:
agaiwted Itylnconsequ nc fthe a mingolthl.pannit.
AIR HANDLING UNIT(OVER I Q ocl,M) CONSTRUCTION TAX
I N o Applic m/Cbm.ct.r Data IXHAUS'f HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
I the applicant orfuturebulldingeocupant store or handle hazardous HEATING UMT(TOIW,WOBTU) Date I t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the
Flealthand SafetyCode Sredon7S532(a)? ]{EATING UMT(OVER 100,000 BTU) - AG �r
0 Ya No
Will the applicant Rome building occupant..a equipment or devices VENTILATION FAN(SINGLE REBID) ', 16S If
which emit haraniom air contamlnanttas definedb the Ba Area Air s 1 ++J
Quality Management District? BORER-COMP PHP OR 100,IXq BTI])
qYes No
have read the h. oue materials requirement.under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) �/4uaeiA:waa
the Califomia Health&Safety Code,Setiom 25505,25533 and 2553/.1
understand that lithe build] does not mrmnuy have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
respo . -
toib' ytontlfy th an,
Mthlacy, menta which most be overpriorce of a Ce o onfie of of racy,
r or aulhorimd agent Data
TOTAL: ISSUED BY;
OFFICE COPY