22744 V APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: 22744
1 n A
I/:Z33 « G G 4
mere ante: V Phone: - APPLICAITONSUBMITTALDATE
<l CITYOFCUPERTINOLBUILDINGDIVISION
C nI
tiacto' Na- k.No: APPLICATION / PERMIT
S rSS277, BUfLDINGELECTRICAL-MU RING-MECHANICAL CATEGORY CONTROL#
Architen/Engineer. Lk.No:
.
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO.
BLUU
- Addre,a: PERMITISSUANCE � . El1:1LICENSED CONTRACTOR'S DECLARATION -
I hereby affirm that l am licensed under provisions of Chapter 9(commere APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ing with Section 7000)of Dwomn 3 ofthe Business and ProfacconsCode,and my
license is in fell rte and effect. L Si PANES _ /,� Our I ,.
Licenre Class Lk.# l�
Date CmdraciorAMPS
ARCHITECPS DECLARATION 201-MAMPS
Rod
7 I understand my plans slug reco
be used as public rds OVER 1000 AMPS SQ.FT.MOOR AREA $/SQ.FT.
❑O❑
Z U Licensed Professional SIGNS ELECTRICAL il p rs ^
!L OWNER-BUILDER DECLARATION SVECIALCIRCUIT/MISC 1 AP—\1
I hereby affirm that l am exempt from the Contractor's License Law for the
FZ~� following reason.(Section 7!X11.5,Business and ProfessionsCode:Any city or TEMP.METER OR POLE INST. M �
uu11 countywhlchrequiresapemtittommtmet,alter, pmve,demolish,orrepalr
92¢. any structure prior m its ante,also requiresthe applicant for such permit to POyygg DEVICES
T�9 �< file a signed statement(hat he is licensed pursuant to the provisions of the mDA / e
Contractors License Law(Chapter 9(mccomingwith Semon 7000)of Divi- SN
MHOSSWIMMING POOL ELECTRIC
slon3ofnhe Business and ProfessioreCode)orthat he is exemptthereftemand
the basis for the alleged exemption. Any violation of Section 70315 by any pUILETSSWIiCHESFI%.LURES
applicant for a permit subjects the applicant to a civil penalty of not more than SC/Or i
c. o five hundred dollars($500).
j Z ❑Las owner of the property,or my employees with wages (heir so
compensation,willdothe work and thestructure W not intended or
k NEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
offered for
5 D sale(Sec.7044.
pply Bu sinessandf property Code:The Contractors License Law t
Q docs netapplytorn owner orthrouh who buildnem orimprwvided con,and
$^
who doessuchwork Mmsel(orthrgughhis ownemployees,provided that such OCC.GROIJbs - RFS.UNITS
Improvements are not intended or offered for sale.If,however,the be llding or TOTAL
improvernambsoldwithln oneyeargfeemplelinn,the owner-builderwill have
i ben of proving that he did not build or Improve for purpose mask.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
[as.at of the property,am exclusively contracting with license PERMIT ISSUANCE /G),
contractors to corstmct the project(Sec.7044,Business and Professions Code: U u
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
bullds or Improves thereon,and who contracts for such p(o)ecb with a FEE SUMMARY -
C tt(actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B 4 P C for this reason
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y N
Owner Date RECEI T#
WOR"A,N COMPENSATION DECLARATION PER TRAP SCHOOL TAX Y_ N_
.ap-�Of hereby affirm that I have a cettifiate of consent to self-insure, FU(71JRFS
or RECEf?#
J ('rtNicate of Workers'Compensation Insurance or a certified copy thereof(Sec.
l 3800,Lab CI GAS E.A.SYSTE14-1 INCA OUTLETS - PARKFEE Y_ N_
Pg11y# q1
.41 7b e _ I RECEIPT#
Cram anv / rrtln i,!li.,.>.3 / GAS EA.SYSTFM-OVER4(FA) BUILDING DIVISION FEES
Lj Certin�reby furnished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
1Cerlified copy W filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRAAY-STORM EA.700F1'. Date RCCCI t#
(this section need not be completed if the permit is for..hundred dollars
($100)orly t•'/1 ENERGY FEE Y_ N_ � .•
I¢rtily that in the pedm
oun<eof the work for which this penult is issued, WATERITEATERWIVENT/ELECTR V c/
1 shall not employ any person in any manner an as to become subject to the WATER SYSTEM/TRFAIINS
Workers'Compensation Laws of California. Date PAID
—
z Z Applicant NEW RESIDENTIAL P1.1,15. SQFT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor - TOTAL:
F U) Code,you most forthwith comply with such provisions or this permit shall be
� > deemed revgkea. BUILDING FEE
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
(L o Ihereby a(Bim that there W a consuucton lending agency for the perfono- s ELECTRIC FEE
M Z ance ofthe wmkfor which this permit W lsseed(Sec.3097,Civ.C.) TOTAL:
U O tenders Name PLUMBING FEE
LL Lenders Addmss QTY. MECHANICAL PERMIT FEE
O Wicenifythatlhavcrcadthbappllationandstatethatthcaboveinformation MECHANICAL FEE
11 Wcoingt building comply with all diyand muhoo representatives
statelaws PERMIT ISSUANCE - FEES/ PAI
} reytlngtobuilding t construction,andhereopertyorin representative o(lhW N
F N city W enterupon
to the,indemnify an
property for inspection purposes. ALTER OR ADDTO MECH.
?
(We)agree to save,Indemnify and keep harmless the City ofCu actInorue Date Receipt#
V against liabilities,iadgmenb,costsand expenxs which may In any way aceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: �-��
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX
Signsturc of Appuant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ha rad ie haaardom HFATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I ealth and Safely Cede Hon 25.532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: T
❑Yes No
Will the applicant or future building occupant use equipment or devices VENTILATION PAN(SINGLE MID) ISSUANCE DATE
which emit ha,raidous air mnlanuants as defined by the Bay Area Air
Quality Management District? _ BIXLER-COMP DEEP OR 100,000 BTU) n � '
4Ye UN. r
have read the hazaNbus materials requirements under Chapter 6.95 of BOILER-COMP(OVER IDQ000 BTU) -
the California Health k Safety Code,Sectiore 2550.5,25533 and 25534.1 NOVunderstand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL 1� _ rl '�(](��
responsibility W notify the occupant of the requirements which most be met u 7• s9s7
p W lssuanmofa CertiBat¢(O mpanry. -
�, l�Q vOf�C( Of y, YO � H1
nor or autharited agent Date ISSUED BY.
TOTAL:
OFFICE COPY