22893 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PE WTNO.
e.Bamg Aaareas:_ �O lg - 22893
wA2 one: APPLICAlIONSUBMINAL A
- CITY OF CUPERTIN0.DUILDING DIVISION
Coat m Lie,No: APPLICATION / PERMIT
BUILDING-ELECTR)CALPLUMBINGMECHkNICAL CATEGORY CONTROL 0
Architect/Engineer. Lie.No: -
t
r QTr ELECTRIC PERMIT FEE BUILDING PERMIT INFO
-
BLDG EL�i PLUMB Nlk�H
r Address: s.�
1'EIiMfT ISSUANCE 11l/G'I
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc. APPUANCESRESIDEMTAL JOB DESCRIPTION
ingwith Sectloa7000)of Dlvislon3 ofthe Buslnessand PrefouiumCode,and my
license is In full force and effect. o-S • 9 l G 3 PANELS
LicenseClan Lie.tl L
Date Contractor UP TO 2DO AM
ARCHITECT'S DECLARATION 2014000 AMPS
oiZ I understand my plana shall be used as public records �MIODOAPS s SQ.Fr.FLOOOAOR''AREA ^S/SQ.Fr.
E z(kCuj Licensed Professional I a W ro
F OWNER-BUILDER DECLARATION / vV
F, ]hereby affirenthal l am exempt from the Contractor's License law for the
7. G following reason.(Section 7031.5,Business and Professions Code:Any city or
Z F., OR]'OLE ISf.
El county
cturech requ ier toIa permit issuanrommteurt, Its,quires th aprovpdemolish,ormit I.
Qg any structuretatement Lhat he gshe requires to the ro suchperNte I -�-j �q O.
y� file a signed statement that he u IlmnaM pursuant to the pmWiore of the
X05Contractor's License Law(Cha er9(commendn with Section 70M)of Divi- VALUATION
s1on3 of(he Business and Professore Code)orthatt he is exempt therefromand SWIMMING POOL ELECTRIC �a�
,-, the bash for the alleged exemption. Any violation of Stolon 7(BL5 by any OUTLETSSWITCHESFIXTURES W
�� appliesnt for a permit subjMs the applicant to a civil penalty of not room that u J 0
five hundred dollars($500). SQFT. STORIES TYPE CONSTRUCTION
R ❑I,as owner of the property,or my employees with wages as(heir sok NSW RESIDENTIAL ELECIR
slat compensation,wllldothe work and thestroctureu not intended or offered for
5 p sale(Sec.70,14,Business and Professions Code:The Contredoes License Law
does not apply to an owner of property who Wilds or improves thereon,and OCC.GROl1P RFS.TINTS -
who does such work himselforthrough his own employees,provided that such
improvements arc not Intended.rotieredforsals.If,however,thebullding or TOTAL �
improvement usold withinmayearofcomplNlon,the Owner-Wilderwlll have
tF(r�urden of proving that he did not build or Improve for purpose.(sale.). QTy, PLUMBING PERMIT FEE FLODDIONE APN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70,14 Business and Professiore Code: -
The Contractor's License Law does not apply to an owner of property who ALTER-DRAW kVENT-WATER(FA)
Wilds or improves (hereon,and who contracts for such plojecta with a FEE SUMMARY
�t adm0a)licensed pursuant to the Contractor's License Law. BACK FLAW PROTECT.DEVICE
LJ f am exempt under Sec B k P C for this reasonrnzq
OwnerDate DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECSIP M
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCHOOL TAX Y_ N_ -
❑1
'
ere
by affirm that I have a certificate of consent to.]Wasure,or a RECEIPT tl
comflcale of Workers Compeneat(onlraurame ora certified cepythereof(See. GAS FA.SYSTEM-I INCA OUTLETS PARKFEE Y N
3800,Lab C.)- RLCEIXI'N
Policy M GAS EA.SYSTEM-0VER l(EA)
Co ray BUILDING DIV]SION FEES
ertified copy is hereby fhMe city GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECICFEE -
CMJed copy is(Ilea with Ne city W pMlon dlWsion. -
CERTIFICATE OF EXEM PTION FROM WORKERS' GREASE TRAP PAID /04%
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA.200FT. DatC CCeI [#
(This section need not be completed If the permit isfor one hundred dollars
(SI00)or less.) WATER HEATER W/VENT/EL[CTR ` ENERGYFEE Y N_
]certify that in the performance ofthework forwhich this permit Is issued,
I shall not employ any person to any manner so as to hemme subject t.the WATER SYSTEM/TREATING '
Workers Compensation Lawsof California.Date - PAID
O Z Applicant after making this Certificate of Exem 1 NEW RESIDENTIAL PLMB. so-Fr.
Daf Recei [#
Z O NOTICE TO APPLICANT:If,a g pt on you
should become subject to the workers'C.mpensat ion proWiom of me Labor , 4 J. I TOTAL:
W Code,you must forthwith comply with such provuiora or this permit shall be DINGXL
W j deemed revoked.
CONSTRUCTION LENDING AGENCY S ]SMI
S G ]hereby affirm that thereis a coretrudion lending agency for the perform- TOTAL: ELECT �a
7 Z ance of the work for which this permit is Issued(Sce.3097,Civ.C)
V O Lenders Name PILjNAXGFE
LL F tenders Addrem; QTY. MECHANICAL PERMIT FEE ANICAL -EE
OLI W Icertilythat l have mad this appBestlonand rtatethat theaboveinformation
4 ucomed.IagreerocomplywithaBdtyandmuntyordinanms and state lawn PERMIT ISSUANCE FE SPAIU
} tA,
relating to building construction,and hereby amhodae representatives of this O`
H city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
_ Z Date Receipt#
(We)agree to save,indemnify an d keep harmless the City of Cu pen
V AIR HANDLING UNIT(TO I0,000CFM)against liabilltles,pdgments,mstsand expenses which may in anywayaccue aceme $ BTOTAL:
against said City In cone uenm (the grantingathis pemmnm. -
Let, �JL7. ARHANDLINGUNTT(OVFRl0000CFM) /� CONSTRUCTIO TAX
Signature.( pplicant/Contractor- Uato / a� EXHAUST HOOD(W/DUCn CONSTRUCTION AX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant m future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date R el t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I lealth and Safety Cod�YeaIe Section 25532(a)? HEATING UNIT(OVER 100,000 BM TO
No
❑Will the applies rat or future building occu pant use equi Fount or devices VFN'DLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management DBiritt? BOILER-COMP GHPOR 100,000 BTU)
Yea ❑�1 No
Thavereadtheh d. mmedaurequimm naunderChapier6.95o( BOILER COMP(OVER 100,000 BTU) P
the Califomia Health A Safcty Code,Sectims 25505,25573 and 25534. I
understand that if the building does not currently have a tenant,that itis my NEW RESIDENTIAL MECH. SQ.Ff
responsibility to neatly the occupant of the requirements which must W met TOTAL: — 91='4 19
prior to issuance a a Certificate of Occas pa racy. ((���yr�[�Nov
19
Owner or authorlud agent Date — 1S5UECLD
p
OFFICE COPY