22875 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project ldendficatlan PERMIT NO.
Bye—Iding Address: 2 2 8 7 5
..or a Nfile: 011e:
d G CITY OF CUPERTINIZ BUILDING DIVISION IQ
Contractors Nama: Lie.No: APPLICATION /PERMIT C '�
�Dh c'r 3 BUILDINGELFCTWCALPLUMBING-M IJANICAL CATEGORY CONTROL#
Architect/Engineer. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
• ' PERhITISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR'$DECLARATION
I hereby afinn that l am licensed under provisions of Chapter9(coommo. APPLIANCES-RESIDENTIAL t 'OF JOB DESCRIPTION
IngwithSMlon7000)of Dlvision3ofthe BuMnemand ProfesslonaCode,and my
license Is in full f0 and affect. PANELS
D en'SLic.It
Lter U Contractor / s SF�Sfl Iva
ARCHITECTS DECLARATION 201-1000 AMPS
OO I understand my plansshall be used as publlc records. OVER 1000 AMPS
SQ.Fr.FLOOR AREA $/SQ.I7.
C
Lirenaed Protesebvl SIGNS ELECTRICAL
6 kFru, OWNER-BUILDER DECLARATION .SPECIAL CIl2CUIT/MLSC `
IherebyafBrce that l am exempt from the Contractor's License Law for the
following reason.(Section 70315,Business and Profeaters Code:Any city or
F O, countywhich Mcf-maaapermit lomvtruct,alter,Improve,demolish,orrcpdr TpMp METER OR10LE INST.
yy any stmcture priorto Its Issuance,also requires the applicant for such permit to ]OWER DEVICES
CC Ile a signed statement that he Is licensed pursuant to the provBlons of the -
�O� Contractor's License Law(Chapter9(commencing with Section 7000)of Divi- SWIMMING IDOL ELECTRIC
,..,� sion3 of the Business.ed PrefessiovCode)Or that he is exempttherefrom and the basis for the alleged exemption. Any violation of Section 7031.5 by any VALU��L
�$4 < applicant fora permit subjects the applicant to a civil pmaky ofeet more than OUTLETSSWITCHES-FIXIVRES O�d �^•.
Efive hundred dollars($500). NEW RESIDENTIAL ELECTR -
I,as owner of the property,or my employees with wages as their sole SQFr. STORIES -TYPE CONSTRUCTION
compensation,will do the work and the structure b not Intended or Offered far
O sale(Sec.7046,Business and PrafeesWns Code:The Contractors License Law
does not apply to an owner of property who builds or Improves the.,and
OCC.GROUP 875.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not Intended oroffered forsale.If,however,thebuildingor TOTAL:
Improvement Issold within One yearefcompletian,the memer-builderwll have -
th&Lurdro
an of pvingthat he did notbulld or Improve forpurposeofsakj. QTY, PLUMBINGPERMIT FEE FIAO
LJ L as Owner Of the property,am exclusively contracting with licensed D—ZONE APNPERMIT ISSUANCE
contractors to construct the pm)M(Sec.7014,Business and Professions Code:
The Contractors License Law does not apply to an Owner of property who
builds or Improves thereon,and who contracts for such p\ojects with a ALTER-DRAIN&VENT-WATER(EA)
cgalpctoHsl lkessed pursuant to the Contractors License Law. ' gp�pLQWrPROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N .
' _ Date RECEIPT M
WORKMAN COMPENSATION DECLARATION
QI hereby affirm that T have o certificate of covens d self-tnwre,ora FI%']URFS PER TRAP SCt900L TAX Y_ N_
3901(labofWorkere'Compensallonlnsurantt ora certified mpythereo((Sec. R_ NX
3BOO,t.6 CJ ap GAS-,EA.SYSTEM-1 INC.40I1TLE l'B PARK FEE Y_ tJ_
Po11ryX /Z�/ L�10 9QRECEIPT#
Com an - GAS EA.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
b
ertlled copy is hereby thcity Furnished. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Ned withhthe city Inspection division. -
CERTIFICATE OF E)(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA 200FT Date - Recei t#
Rhe...) need no[becompieted if the permit borons hundred dollars
.($100)Oify,thIn WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
net employ
oy an person
in an thework
an as to become,h this xub)ecrmit Is blued, —
I Whale not employ any person in any manner an v to become subject to the
Worlicant mpensation Laws of GB(ornb.Date - WATER SYSTEM/TREATING PAID
O Z Applicant Date Recei t#
Z O NOTICE TOAPPLICtt.tha.Ker making this Certllate of Exam Date NEW RESIDENTIAL pLMB. SQFT.
should become subject to the Warken'CompevaUon provisions of the Labor TOTAL:
~ (/l Code,you mostforthwith comply with such provisions orlhis permit shall be BUILDING W > d erred revoked.
a -CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a mvtmetion lending agency for the perform ELECTRIC FEE
O ante of the work forwhich this permit is Issued(See.3097,Civ.C.) TOTAL:
v _ Lender's Name - PLUMBING FEE -
LL I- LEndae.Addrcas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ittltlfythatl haveread this application and statethattheabove information
iscOmact.Iagree to comply withal)city.ed county ordinances and nate laws PERMrr ISSUANCE FEES PAID: -
} N relating to building construction,and hereby authorize representatives of this -
Z city to enter upon the above-mentioned property for Inspection purposes, ALTERORADDTOMECH.
(We)agree to save,Indemnify an d keep hermiea the City of Cuperim. Date - Recei t#
V agalna Obi@les,}ndgmente,mets and expenses which may In anywayacaue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
.gal aid City In mnsequentt a ting Ofthis permit.
ATR HANDLING UNIT'(OVER 10,MDCBM) CONSTRUCTION TAX
51 no reot utt C ntrano Date EYHAUSTFIOOD(W/DUCT) - CONSTRUCTION TAX PAID:
H9 \RDOUSMATERIALS DISCLOSURE
Willthea Ilan orfuture bulldiagocrupantstme or handle huardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the 'Date Reeel t#
I to
ealth and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
F-11Yes N No TOTAL;
Will the applicant or future building Occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
•
Management Magcnt DlsMnT. i'' BOILER-COMP pIB'OR 100,000 BTU)) -
YYes . No.
l have read Healthe h
Sales Code,Se requirements 25S 5,25M and 2S53r 6.95 of BOILER-COMP(OVER 1170,000 B111)
the Call(ornla Health 4l Safety Code,Sections 7550.5,25533 and 75534.I
understand that if the building doe.not currently have a tenant,that it is my NEWRESIDENTIALMECH. SQ.Fr f")r3� 'I 1 J 1�t)r
responsibility to notify the Occupant of the requirements which must be met OCI 1- J
prior to iseuarm of a Certificate ofOccupancy.
0 D 48111 CQ�\
Owner or aulhorlred agent Date ISSUED BY.
'TOTAL:
OFFICE COPY