22793 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Address;ildln Project Identification PERMIT NO.
22793
wnera Name: one: ` A
(j— 6 CITY OF CUPERTINO-BUILDINGDIVISION
akcrsntra o•s Name:.. Llc.No: APPLICATION /PERMIT BURDINGELECTRLCAL PLUMBING-MECHANICAL CATEGORY CONTROL#
Archltea/Engineer. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERSRTISSUANCE (� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that am licensed under provisions o(Chapter 9(cornmene, APPLIANCES-RESIDENTIAL JOB DESCIUPTION wy
ingwlth Section 7DOO)o(Division 3ofthe Budnessand Prodesslons Cod1'.9ga.d my
license Is In full force and effect. PANELS ossa. , V.V
License Chas .oro 1 �/') ,M'^l
Date Cantntor lUPTO200AMPq
ARCHITECTS DECLARATION 201-1000 AMPS
M2 I understand my plarashstl be used as publicremrde OVER1000AMPS SQ.FT,FLOOR AREA $/SQ.FT.
O
SIGNS
ELECTRICAL
�j Licensed ProfessOional
L•LECTRIGL
N OWNER-BUILDER DECLARATION
0, SPP.CIAL CIRCUIT/M75C
1harbya(firm that from the Contractor's License Law forth.
7.O�a followingreason.Section 7031.5,Business and Profession.Code:An d or
OZi.� Y city TLTSP.METCR ORIOLE INST.
P� rountywhlrh requBesa permit,omwrequiratheaprovgdanolbh,ormit to
W6anystruduretatemeIts hat he Is also rcqulrersuant to the faeuch lors of its POWER DEVICES
Ue•C I+ floe a Signed&cement that he is Ilamsed9(core pursuant it the ton 70oru of the
I. Contnttor's License Lew(Chapter9(rnmmen ng withS ttlan 7000)mlDvl- SWIMMING POOL ELECTRIC
BOJ slon3 o(the Business.rad Professlo.s Code)orthat he Isexempttheredromand - VALUATION
.....77777 the basis for the alleged exemption. Any violation of Seaton 7031.5 by any OUTLETSSW[TCHFSFU(TURES
appU..t fora perMbubjets the applicant to a civil penalty odors,more than
{Q five t dollam(4500).
e.owner of the property,or my employees with wages as their sole al R69DENTIAL ELECTR_SQ.F. STORIES TYPE CONSTRUCTION
mperadlon,wnl do the work,and thestrutum is not Intended or offered for
O le(Sec.7044,Business and Prof ns o es Code:The Contractor.Lt...Law
$$ does not apply to an owner of property who Wilds or Improves I hereon,and OCC,GROUP RES.UNITS
whodoeaeuchwork himself orthrwgh hieownemployees,providedthat such —
Improvements am ent intended oroffard formic.IL however,the W ildingor TOTAL:
improvement issold withinoneyearofcompletoMtheowner-W Oderwill have
tlBIkurden of proving that he did not bund or Improve for purpose ofsale.). QTY, PLUMBING PERMIT 'FEE `
L J FLOOD TONE MIN
L as owner tr the property,am exclusively ental I' with licensedconPERMIT ISSUANCE
The Crams to crsruwt the project(Sec apply
Business and Iof property
Code:
The Coor Improves
License Law dare not apply tc an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for each ptojem with a ..
c[:]I am c.ompt undeptonr
Scttothe Conlntor'sLicense Law. BACK FLOW PROTECT.DEVICE FEESUMMARY
LJ I am exempt under Seo B&P C for this mason
DRAINS-FlAO ROOF A CgND S A Y— N—
. Owner Datc I RECEIPT p
WORKMAN COMPENSATION DECLARATION FLC'NRES PER TRAP[-- P- ice• SCid L AK Y— N
❑I hereby affirm that I have a certificate of consent to self-Insure,or a R��N
cemincate of Worken'Comperua,lonlreurance as certified copy thereo((Se<. GAS EA.SYSTEM-1 WC.IOUTLEIS`� A ' Y N
3800,Lab CJ
Policy p CAS E.SYSTEM-OVER d(FA) DINRDZG DI#
Com any BUILDING DIVISION SEGS
ffCetlfled copy Is hereby fumished. CREASE/1NDU LW0 GI-IE KPEE
MCatified copy Is filed with the city Inspection division.
CERTIFICATE OFIXEMYTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20071'. Date Remi t#
(TElasetlon need not be complied,the parsed,V(a ova hundred dollen
(E100)orlessJ WATER HEATER W/VENT/ELECTR ENERGYFEE Y' N
Illnlfy that to the performanceny he workmanner so which as to
eemdHsleaved, —
I shall not employ any Lars.In any manner se as to become subject to the WATER SYSTEM/TREATING
Workera'Compenutlon Iowa o/Callfomla.Date PAID
-
Z Z Applicant NEWRESIDENTIALPLMB. SQ.Fr. Date RCmj t#
O NOTICE TO APPLICANT;If,after making this Certificate of Exemption,you _
should become subject to the Workers'Compemsatlon providoru of the Labor TOTAL:
CC N Code,you must forthwith comply with such provisions or this permit shall be �� D
WJ deemed revoked. '
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffirm that there le amrutrutlon lending agency for the perform - TOTAL: ELECTRIC FEE
Z ance of the wc, for which this pe mit is lssued(Sec.3097,CIv.C.)
V O Lander:Name PLUMBING FEE
LL F Le.der.Addrcas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lcertifythailhavereadthisapphaHonandtlatelhatmeabovelnformation
4 bmrtet.I agreelo complywith all city and county ordinances and date laws PERMTTLSSUANCE FEES PAID:
>_ W relatingtobulldingmrutrvtlon,and hereby authorize Npresentatveso(this
F Z city to enter upon the above-me toned property for inspection purposes. ALTER OR ADDTO MECH. Date RCCCIP f#
V _ (We)agree to save,indm
enify an d keep harmless the City of Cupertino
against lbbillties,judgments,rodsand expensawhich may btanywsyactIT ue AIRHANDLING UNITO 10,000 CFM)
agalr,eta Gtyln consequence of the granting of this pemnitSUBTOTAL:
2 9/ AIR HANDLING UNIT(OVER 1Q000 CFM) CONSTRUCTION TAX
Boa reo(Applicant/Contractor + Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum bufiding occupant store or handle hazardous HEATING UNIT(TO ID0,000 BTU) Date Recei f#
material as defined by the Cupertino Municipal Code,Chapter 933 and the
I Iwllh and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
YoNo
Wllltheapplimnt or arum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISS[P&DDATE
which emit hazanfous air contaminants as defined by the Bay Arca Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4 Yes ( 1 No
have read the Faze, ua materials requirement.under Chapter 6.95 of BORER-COMP(OVER 100,00)BTU) aEP 2 a 1��1
the Cailfc roM Health&Safety Cede,Set 1..25505,23533 and 25534.I
undenta nd that lithe building does not currently have a tenant,that R ci my NEWRFSID=, ALMECH. SQ.F7.
responsibility to notify the occupant of the requirements which must Wrtet �� C
prior to issux ace of a Certificate of Occvps nry. u a
Owner or authodzad agent Date ISSUED BY:
TOTAL: —
OFFICE COPY