22563 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Huilding Project Identification PFRMITNO.
Building Address: 22563
ner, ame: one:
Aq CITY OF CUPERTINO-BUILDING DIVISION �^' _—
uc. APPLICATION / PERMIT a l[
l 51 BUILDING-ELECTAICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL N
Architect/ gineer. Lie-.No:
Qin' ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
PERMITISSUANCE E:1 101 10:1LICENSED CONTRACTOR'S DECLARATION
I henn.firon —that licensed under
provisions of CmcAPPLIANCES-RESIDENTIAL CSRESIDEfL
IhSection7")of Dlalsion30flhaflusi rid,PfessionsCode.and CII ]OB DFSCRE'ITOIN
I=IChfjqandLid[feR. nPANELS
Lcea /I
—IM TO 2DO AWS
�
Date_ Contract
ARCHITECT CLA ATIO 2014000AMPS
µO�OZ Iunderstand my plans shall be used as public records, OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
E od E Licensed Professional ` SIGNS ELECTRICAL
GGGG LED f N
Qyaffjm OWNERexUILDERmptfro DECLARATION SPECWLCIRCUIT/MLSC , e Nam
7h' owingIhemrssion. Scedusthat I exemptfromthe Contractorb Llcenx Law fee the U K
following reason.(Section 7031.5,Business and Pref inions Code:M or
FIQQpQQp"'� county which requW a permit to construct,alter,bnprove,demolish,or pair TEMP.METER OR POLE INST.
� .c
any structure prier to its Luuance,also requires the applicant for such permit to POWER DEVICES
yinµ file a signed statement that he it;licensed pursuant to the provision,of the DTE
µ Contractor§License Law(Chapter 9(commencing with Section 7000)of Dfvl- SWIMMING POOL ELECTRIC
i-E s1on3ofthe Bus .n dProf ionsCae
ode)orthathebempttherefmmand VALUUAWN
�! the basis for the alleged exemption. Any violation of Section 7031.5 by any 7 ((�J
G
applicant for permit sub' the applicant to a civil penalty OUTLETS-SWITCHES —/ QO r
PP Pc R"t' PP P ty$not rtnrethan
O five hundred della.(1500).
l,asownerofthe property, NEW RESIDENTIAL ELECTRSQFr. STORIES 7'YI'E CONSTRUCTION
CSG nsation,willdothwk.and thesuactture is notIntendedor offered for
5 O sok(Sec 7066,Business and Professions Code:TM Contractors License law
does not apply to an owner of property who builds or improves thereon,and .
who docs such work himself orthrough his own employees,provided that such OCCGROUT' RIS.UNITS
ImP awarrunts arc not Intended oroffered forsak.I(however,thebullding er TOTAL:
b^P vementtasddwlthlnomyearofcamplelon,theowner-buBderwilltave
t)L�nrdnof proving that he did not build ornnprove forpurpoae ofsale.). QTY. PLUMBING PERMIT FEE FLpO z,pN ApN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7064,Business and Professions Code:
MContractor's License law does not apply to an owner of property who AyppR DRAIN&VENT lEA)
and improve,thereon, d who contain for such p(ojects with a
cIJ 1
,ffiCt°rW licensed pursuant to the Contractors License Law. FEE SUMMARY
am exemp under Sec. B&P C for this reawn B/sCIC FLOW PROTECT.DEVICE OUTSI DE If
Purser N DRAINS ROOF,AREA.GOND. SAMTARY Y N_
Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FDCURES,PER TRAP SCHOOL TAX Y N
nd hereby affirm that I have o Insurance
of consent el pythemo ora RECEIPT N
3800,certiflate°fWorkere Compensatl°nlnsuran eracertBled copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS
38 W,Lab CJ PARK FEE Y N
Pulley Y RECEB'F N
Com lanyCarl GAS EA.SYST[h1-0VER d(FA) BUILDING DIVISION FEES
I ICertiBed copy k herebyfurnished.the
GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
rGA�-r'[lerti/ied copy h(fled with the tlty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thlssamon need not becompleted lithe permit is foronehundreddollam SEWER-SANITARY-STORM EA.XsBFT. Date Recei t#
(5100)offy that
WATER HEATER W/VENT/ELEcM ENERGY FEE Y N
I certify that o the performance any
m week fa,as to h this penult is to ti;
1 shall not employ any person In any manner m ns to become subject to the
Workers Compensation laws o(Callfomh.Data WATER sysrFab/'rnEAn"c PAID
O Z Applicant
Z O NOHCETOAPPLICAM:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQyL Date Remi t#
should become subject to the Workers'Compensation provisions°(the Labor TOTAL:
~ N Code,you must forthwith mmplywith such Provisions orthls permit shallbe
-. --a deemed cooked. BUILDING r O
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z a eofth work for
them haeonswHnu lending agency 097,Civ.C.)
perform TOTAL: ELECTRIC FEE
O occur'the work!or which this permit hLasued(Sec.3097,Civ.C.)
V Iunder.Name PLUMBING FEE
LL I— <nderiAddrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertitythatl have read thbBa
apptlon and satethatthe abovelnfomvtlon
C is correct.Iagree t°comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
W relatlag to building ronatructi°n,and herebyauthodzereprexntstivesofthis
I- Z chytoenteruponthe above-mentioned propertyfor Wpe Hon purposes. ALTERORADDTOMECH.
V Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
against liabilities,judgments,mets and expenses which may in anywayacome AIRHANDLING UNTr(TOIQ"CFM) SUBTOTAL:
agalrat said City In consequence of the granting of this permit.
AIRHANDLING UNIT(OVFR 1o,"CFM) CONSTRUCTION TAX
Slgrutureof ApplI rt/Contractor Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheappllcant or future building occupant store or handle hazardous HEATING LINT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reeeit#
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
Yes MN. TOTAL-
Willthe
' ichrotasi,ardntorfuontaminants occupant use the equipment devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants a,defined use
the Bay Arca Air
Quality Management District? BOILER-COMP OHP OR 100,DM BTU) �A`®
91 Yrs g No
ae read the hair us materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Glifima Health&Safety Code,Sections 25505,25533 and 25536.1 �� es �aQl
understand that if the building does not currently have.tenant,that it h 11 my NEW RESIDENTIAL MECH. SQ.FT. v s�s7E
responsibility to notify the occupant of the requirements which must be met Y
prior to issuance a a Certificate of Occupancy.
at Comfim
Owner or authorincd agent Data k
TOTAL: ISSUEDBY: Q
�_ OFFICE COPY