22211 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Pru ed Identification } - PERMIT NO,
BuBdio Addrms e k - = o 22211
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A� -
APPIZ
APPLICATION / PERMIT
V CITY OF CUPERTINO-BUILDING DIVISION � +� �.
ractor.wme: ue."°: 7
BWLDINGELECTRICALPLi1MBING-MECHAMCAL CATEGORY ' CONTROLN
• act/ seer 1 Lie No: _
'QTY', . ELECTRIC PERMIT',' Ij',FEE'
"'t l�. .;VBUIGDING PERMIT INFO ', .,,
Address: - PERMITISSUANCE ,' III
LICENSED CONTRACTOR'S DECLARATION u
I herebyaBtrm that l am Ocrosed under provisions of Chapter 9(mmmene- APPLIANCESRFS7DENTIAL ]OB DFSCRI"TION
Ingwlth Sedton7000)OfDlvislon3ofthe Businessand Pnfenivn.Cude,and my - 7—
license la In full force and-effect. PANELS
License Clan LIe# '
Date Contractor
ARCHITECTS DECLARATION 201-10W AMPS '
�q+on 7p ,.l understand my plana shall be used as public records. OVER 1000 AMPS SQ.17.FLOOR AREA S/SQ.FT.
&� Licensed Professional - _ SIGNS ELECTRICAL - / - I(( SQ
6 OWNER-BUILDER DECLARATION
'
Ihercbya(Ortexempt xemp[fromlhe Contractor's License law far the SPECIAL CIl2CUfT/MISC ,
p followieg resson.(Section 70315,Business and Professions Code:Any e ty or
OF Z F.u9TEMP.METEi OR POLE,NST.
countywhkh requires:permitto torutwd,alteq improv:,dertnlbh,or repair
ggg anystmmmpriortoltsNwance,.L requlrestheapphuntforiudhpermitto POSER DEVICES
' Ole a signed statement that he V licensed pursuant to the provisions of the
3q Contmene.License Law(Chapter 9(commencing with Section 7000)of Divi.
H sive 3°fthe Businenand Profemloro Code)or the he b exempt therefrom and SWIMMING POOL ELECTRIC VALUATION r O
0 the basis for the alleged exemption. Any violation of Section 70315 by any OUTLE7SSWITCHESFI%TURES O !�D D
applinntfora pemdt subjects the app0cant too tivll penalty of seat more thin '
$ five hundred dollars(5500).
1 as owner of the property, NEW RESIDENTIAL ELCCTR_SQ.FT. STORIES TYPE CONSTRUCTION
?< p perry,or my employee:with wages r thele sole
compensation 7lon,Business and
work and ProfessimusthesCode:
o e:The
not ommerce or offered for
O do.real appy to et ower of
who builds
or imp..the.Lftcnslaw
�$$ don not apply to m owner of pro ugh hi h v..rrs oe improovided eoR and OCC.GROUP RES.GNU'S
whodoes orfsuch amen himself ed orvugh hisow formic.
If, owe provided ildinghat h
improvements sold lntendneyearferect(orsale the however, deer ill have TOTAL:
Improverrr:nt lssoldwithlnoneycaro(complellonThe owner-bullderwill have .. ,
th medenof proving that he did net bund or improve for purpose of sale.). Qjy4 PLUA•IBING•PERMIT% "171.12, FLODD ZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014 Business and Professions Crain: ,
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
bullds or Improves thereon, and who contracts for such pr,°jecta with a
m ctor(s)Bcensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE E• `�'FEESUMMARY+'! . '1 "
Lf I am exempt under Sec. B k P C for this reason
DRAINSIR ROOF,AREA,GOND. SANITARY - Y N
• Owner - Date RECEI7N
WORKMAN COMPENSATION DECLARATION MTURES PER TRAP SClil70L TA% Y_ N_
01 hereby a(Orm that 1 have o ce Insurance
of consent to opythwre,or RECEIPT#
certificate of Worken'Compensativn lruurance ora certified ropy thereof(Sec. GAS FA.SYSTEM-1 INC.40I1TLETS " PARKFM Y - N
3800,Lab C.)
Policy N RECEIPT N
GAS GA.SYSTEM-OVER 4(EA)
Co�MOY BUILDING DIVISION PEES
i.Certified ropy Is hereby tarnished. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy R filed with the dry inspection division.
CERTIFICATE OF EREMPTION FROM WORKERS' . GREASE TRAP PAID
COMPENSATION INSURANCE
is(or one hundred dollars SEWER.SANITARY-STORM EA.200FT. Date RcC i t#
(TMssedlon need sea be completed lithe permit
(5100)rtifytJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I artily that In the pedomunce o(the work forwhich this Permit Is Is WATER
I shall out employ any person In any manner ro as to become subject to the WATER SYSTEM/TREATING Workers Compensation laws of California, Date PAID
O Z Applicant
Z O NOTICETO APPLICANT.It,after making this Certificateof Exemption,you NEW RESIDENTIAL PLMS. SQ]rf. Date ReC i t#
should become subart to the Workem Compematlon provision:ofthalabor - TOTAL:
N3 Code,you moat forthwith comply with such provisions or this permit shall be T - .Z _ n
deemed revoked.
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE
a IhembyafBrmthat there Is a construction Nndingagenry loithe perforrsi TOTAL: ELEC'T'RIC FEE
Z ane,ofthe workforwhiehthis permit Is Issued(Sec.3097,Clv.C.)
U O Lender.Name PLUMBING FEE
LL F Lendcr'a Address avercad t hQTY; MECHANICAL PERMIT* E '-' MECHANICALFEE ,
O W ,
that l his applications ed state that the above Informal].
1 bcorren,Ia comply with all city and county ordinances state lawn PERMIT ISSUANCE 17 $ L
} relatln ulldin construction,and hereby authorize representatives ofthis - -
2 tit enter upon eabove.mentioned property for InspectionT E
Inspection purposes, ALR OR ADD TO MECH.
(We)agree to ve,indemnify an d keep harmless the City of Cupertino ate' ReCc Pt#
V agalrutllabt0tl ,pdgmenll,.Iandexpenseawhlch.ylnaoywayam a AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL• .Z.
ago Inst sal try it tons uenre oft a f this permit
AIR HANDLING UNIT(OVFR I O,OW am) CONSTRUCTION TAX
SlgwmrcofA59
p ram/Comractvr - Data EXHAUSTHOOD(W/DUCT CONSTRUCTION TAX PAID:
. HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stomor handle hazardous HEATINCUMT(TO]OO,0001371J) .Date ROCeI t#
material as defined by the Cupertino Murddpzl Code,Chapter 9.12,and rhe
Health and Safety Code SccBon 25532(a)i HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yes N No -
Wllltheapplicanrorfuture building occupant use equipment or devices VEMILATION FAN(SINGLE RESID) ISSUANCE -
whlch einit haxandous air cvntamlmnts m defined by the Bay Area Alr DATE
j.-kNCNCE
E
QAManagement District? BOILER-COMPDHPOR100,0(IOBTU) .
u4 az
Yea dO
have read the ha❑u°materials rcquiremenls under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) ' 111fI( i 71A�,�
the California Health k Safety Code,Sections 2550.5,25533 and 2:534.1 aJVn 1'
understand that lfthebuildlng don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
- responsibility to notify the occupant of the requirements which must be met /� #s��
priorto Lnuanmofa CcAificatevfOcvpancy. city of I(IA
Owner or authorized agent - DateI-
. ..TOTAL: ISSUED,OY: 'VL� l v
OFFICE COPY