22612 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pre'eC ldentilimtion _ PERhflT NO.
Building Addreas: /�N�C
2I 6 I L.4 I0 C �ti N G G o
ra one:
CITY OF CUPERTINO-BUILDING DIVISION — �
contractor's Name: Lie.N. APPLICATION / PERMIT
�•� BUILDINC ELECnUCAL- UJ.MBINGMECHAMCAL CATECARY CONTROL N
Architt/Engineer. Lt.No:
QTY •ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreaa: - PFRFBTISSUANCE a 00 ❑. ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hth Sechfflrmthat lam0)mDiv Bcensedunder inessadPro Chapter asions9(le,and c- APPLIANCES-RESIDENTIAL JOB DESCRQ'TION
Inensei Section fore 7 ofd effect. tthe8usinesaand Pro@.alone Code,and my
license Iain lull form and effect. PANELS
License Class -o LIC.N
Data ContraRor'-
L UP IQ 200ANM5
ARCHITEC7PSDECLARATION 201-IOOOAMPS
�Z I understand my plans shall be used as public records. OVFR1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
µ1 OC
m d o Licensed Professional SIGNS ELECTRICAL IV A L E D IN
f w OWNER-BUILDER DECLARATION
m SPECIAL CIRCUIT/MLSC T E R
I.., 7 Thereby afOrmthatlam exemptfmmthe Contractor's Licenselaw for the
�OF� following reason.(Section 7031.5,Business and Professions Code:Any city or Timp.METER OR POLE INST. P
.a county which requlresa permit tomnstruc;alter,fmprove,demolob,orrepalr
anystrocture priorto its asuance,also requirmtheappBmnt for such permit to ['OWER DEVICES
c V file a signed statement that he is Bmnsed pursuant to the provisions of theJ `7
3n[�' Contractor.License law(Chapter9(romoncri with Section 7000)of Divi- SyyP{MING POOL ELECTRIC WE
F�On sion3o(theBu3nmand ProfemiomCode)orthathebemmptthem(mmandVALUATION— W
G the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESFIXTURES Q r
applicant for a permit subjectsthe applicant to a civil penalty of not marethan
fi�eJiuns ed owner ars of the
pro NEWRFSIDENCIALELECTR SQFr. STORIES TYPE CONSTRUCTION
zz I,asowneroftheproperty,orho emturvisawithwages. rtheirsole
F~ < cmpensatlon,wBldothe work andehestrodureisno[tt(fended or offcPed for
$a q sIn(See,7^'Biisiness and Professions Code:The ContraRoes License law
Q$ docs.not apply to an owner of property who Wilds or improves therron,and OCC.GROUP RFS.UNITS
does such work himself orthrough his own employees,provided that such -
improvementsre
anot intended proffered forsale.If,however,thr Wilding or TOTAL:
improvement baud withirimeye.r.femo,leti. ,the owner-bullderwill have _
tl yrden of proving that he did net Wild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE F DWp APN
u I,as owner of the property,am exclusively=trading with licensed
contractors to construct the project(Sec.7054,Business and Professions Code: PERMIT ISSUANCE
The Contractor's License law does not apply to ani owner of property who ALTER-DRAIN k VENT-WATER MA) _
Wilds or Improves thereon,and who contracts for such projects with a - - _ FEE SUMMARY
ro,,➢➢..t{{actor(.)licensed pureuant to the Contractor's License Law. gAIX FLOW PROTECT.DEVICE
LJ 1 am_ exempt
pt undeq SeC'1_-/.____.._ , B k P C for this reason 'm ES
Owner pin an4GE V /P Dale .0 —Ir4� DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIPT#
WO AN COMPENSATION DECLARATION .PER. , SCHOOL TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to self-lnsure ora FD( RECEIPT N
M00,Late o(Workeri Compensation Wurance aracertB4d copy tM1enrof 6ec: GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y ' N
3800,Lab CJ RECEFPT M
Policy/ - GAS EA.SYSTE OVER4(EA)
Com ray BUILDING DIVISION FEES
ECchified copy Is herebyFurnished.city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
❑Certified copy lit filed with the city Inspection division
CERTIFICATE OF R( MPITON FROM WORKERS' . GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRARY-STORM FA.2WFT. Date Reeel 1#
se
(Thlsnion need not be completed If the permit isforom hundred dollars
($IW)or less.) WATERHEATFRWiVENT/ELECTRENERGY FEE Y_ N_
m .
I minify that in the performance of the work for which this permit is issued, '
I shall not employ any person in any manner w as to become subject to the WATER SYSTEM/TRIATING
Workem'Compensationtawsof CallfornU. Date PAID
—
z Z Applicant NEW RESIDENTIAL I'LMB. $Q.FT. Date 12ecel ill -
Z O NOTICE TO APPLICAN'T:If,after making this Certificate of Exemption,you
should bemme subject to the Workers'Compensation provisions of the Labor - TOTAL:
� ; Code,you most forthwith comply with such provisions or this permit shall be BUILDING FEE
W _ deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC PEE
1 O I hereby affirm that there is a construction lending agency 97,C for the perform ELECTRIC FEE 0
0 Z an sten,Nwork for wMch this permit isissued(Sec.3097,Civ.C.I TOTAL:
02 [enders Name � PLUMBING FEE
N- Lenders Address QTY. . MECHANICAL PERMIT FEE
OU
I certlfythatl have read this applimhat tionand statettheabove information MECHANICAL FEE
1 uscoined.I:gree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
} relating to building construction,and hereby authorlu representatives of this
F N city to enter u Pon the above-mentioned property for inspection pu rposes. ALTER OR ADD TO MECH.
Z Me)agree to save,IndemN/y an d keep harmless the City of Cupertino Date Receiptq
V d me ,costa and which ma ]nen cense AIRHANDLINGUMT(TOl0,000CFM) - _
agaWtllabllltim,ju g y ywaya SUBTOTAL: 3
d ity In cons t race oft i o(this permit
�_� AIR HANDUNGUNR(OVER IO,000CFM) CONSTRUCTION TAX
tutu of Appica t/Conacto Data L/ EXHAUST HOOD(W/DIKT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO ID0,000 BTU) Date Roeei Iq
material as def]tied by the Cupertino Municipal Code,Chapter 9.12,and the -
health and Safely Cade Section 2532(.)? FIpATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No -
Willtheapplicantorfown,beilding occupant use equipment or devices VWRLATION PAN(SINGLE REBID) ISSUANCE DATE,
co
which emit hazardous air ntaminants as defined by the Bay Area Air p A,
Quality Management District? BO[LER-COMP PtII'OR 100,0(l(]BTU) AMD
Yet ❑No
P
haveread the
ealth&Ssf materialsodectiom m05,l?S der DaCha nd 11..95 of BOILER-COMP(OVERl00,000BN)the (n� l
understand California
i(Ilhe building does not asorrentlyhave a tenant that itlis my NEW RESIDENTIAL MECH. SQ.FT a •991
bilis to notify the cans tof the t which must ne met ��
poor to Y Y Pan requirements
prior to Issuance d.Certificate of Occupancy.
CI
Owner or authorized a gent Data ISSUED BY:
TOTAL:
OFFICE COPY