22892 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
BuildingProtect Identification - PERMIT NO.
Build Ing Addma, saa. 22892
wnFI ani•: �, t _ Roy+. SUBMITTAL
_M Q� yy� w CITY OP CUPERTINO-BUILDING DIVISION I
c°"'OrrrO`.-1.7 N ° APPLICATION / PERMIT
BNLDING-ELECTRICALPLUMBINC-MECIIAMCAL CATFS'.ORY CONTROL M
Architect/Engineer. He.No:
'QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add... PEItFRTISSUANCE �• ISI — 11 1:1' LICHNSF.D CONTRACTOR'S DECLARATION — u
I hereby affirm that l am Licensed under provisions of Chapter9(comment, APPUANCES.RESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of DiWsion3ofthe Businemand PmfessionsCodGand my
Lens Isla full farce and ic.il PANELS
License Clam LIeN E.I.Date Contractor
ARCHITECTS DECLARATION W14000A.M1'S
X [understand eny plans shallbe uaed as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Cb,�j Licensed Professlowl SIGNS ELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISC
7 �a IhembyifOrm that l amexempt from the Contractor's License Law for the
bpp following moron.(Section 70(11.5,Business and Pmfessbne Code:Any city or
Z I—@ TEMP.MILFI OR POLE INST.
� cwntywhlchmqulmsapert ttommtmd,alteplmpmve,dem lish,ormpadr
g anystmcture person Its Issuance,also requires theapplimm forsuch permit to
F NK Ole a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
Contractor.License Law(Chapter 9(commencing with&-1-.7000)of Dlvl-
O y SWIMMING POOL ELECTRIC
S sie basis fo thealleged Professions Any)violation f Section
therefrom and VALUATIC ! �
the basis for the alleged exemption. Any t tolacivi of Section 7011.5 by any OUTLETSSWI7'CHFSFIXTURFS 2 V 0
O eppVonffor a permit subjects applicant toaciWl penalty of not nnre than
live hundred delta.($500). NEW RESIDENTIAL ELECTRSQ.FT• STORIES
TYPECONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sole
�7Q compensation,will clothe work andthestructure lases intended or offered for
5 D sale(Sec.704Z Busbmas and Pmfesslom Cade:TM Contnd.e.Llcerse Law
( r3$ does not apply to an owner of property who builds or Improves thereon.and OCC.GROUP RES.UNITS
who doessuchwork hlmelforthroagh hisownemployees,provided thatsuch
improvement.are not Intended motioned(ortale.If,however,thebuilding or TOTA
Impowemrm issold wilhlnoneycarofcompletiontheowner-bu0derwill have
tlurden of proving that he did not build or improve for purpose olule.). QTY. PLUMBING PERMIT FEE FT.00D TONE APN
LJ I,ae owner of the property,am exclusively contracting with licensed
contactors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contractor.License Law does not apply to an owner of property who ALTER-DRAIN k VEM-WATER[FA)
beIlia or Improves thereon, and who mntnce,for such plojecte with a
CgR.t[aa r(.)Brengel pursuant to the Contraciers License Law. FEE SUMMARY
IJ I no exempt under Sec. B k P C for this reason RACY FLOW PROTECT.DEVICE
•
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N�Owner Date REC IPT N
WORKMAN COMPENSATION DECLARATION FIXTVRF.S PER TRAP SCIdOOL TAX Y— N_
QI hereby aff m,that I have a mrtiRrate of consent to self-nsere,ore RECEIPT N
certificate of Workers'Compereation Trmurance or a certified copy themof(Sec.
M00,Lab C.) GAS EA.SYSTEM-]INCA OUTLETS PAR](FEE Y N
Policy RECEIPT# -
GAS E.A.SYSTEM-OVER 4(EA)
Y BUILDING DIVISION FEES
^fflied copy is hereby filed
the city CREASEANDUSTRL WASTE INTERCEPTOR PLANCHECICFEE
crtlOed copy Vfiled with the city Inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2007.. Date Recel t#
(This action need not be completed Bthe permit Is forms,hundred dollars
0100)or1em') WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
(certify that Ntan person
°/theworkso as to bco pesubjcWucd, —
I shall net employ any person I^any manner w as to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California.Date � PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Dale Recel t#
Z O NOTICE TO APPLICANT:If,after making this Certillate of Exemption,you
should became subject t.the Workers'Compensation provbiom of the Labor TOTAL:
CC N Code,you=at fort hwith comply with such provident or this permit shall be BU
deemed revoked.
CL C CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffimthat there is a rorsttuction lendingagency ferthe perfomory TOTAL: ELECTRIC FEB
VZ anceoflhe workforwhlch this permit is Issued(See.30W,Civ.C.) ELECTRIC EEE'
O Loader.Name '
IL F Iander.Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O O Icertifythat I have readthis applicationand state that theabeve Information
i.cerrect.Iagreeto comply with all city and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
>• IL relating to building construction,and hereby authom,........ allvra of this
)— N city to enter upon the abovcmenttoned property for Inspection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d harmiess the City of Cupertino Date Receipt#
V 9Willth
,rydgment.,cestsand p sae whichmay In enywayacame AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL'
in ronsequence of the ntingof th it. -
m AIR HANDLING UNIT
/DUCO IO,000CFM) CONSTRUCTION TAX
n antra late IXFiAUSTHOOD(W/DIKT) CONSTRUCTION TAX PAIHATARDOUS ATERIALSDISCLOSU
icant or future building occu ntstore er handleh minus HFATINGUNIT(TO100,0008TU) Date RCCei f#
material a.defined by the Cupertino Municipal Code,Chapter 9.12,and the
I tealth and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
n Yea No
Will theapplicant or tum building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) IS§QQDATE
which rout haaardous ab e.maminanb as defined by the Bay Area Air
Quality Massgement District? BOILER-COMP O)E'OR 100,IXq BTI!)
4 Yes No so/ y r
havrrced Healthe h
er us Cocle,Scetlo 25505,tundernd2S5 4.I of BOILER-COMP /e•• JC�y
the California Health&Safety Code,Section 75505,25$33 and 2S534.I //
understand that lithe building don nm cv,..tly have.tenant that It B my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant etthe requirements which moat he met
prior to issuance of a Certificate of Ottupanry. /
Owner or authotiud agent Date ISSUEDBY:
TOTAL:
OFFICE COPY