24222 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PEI MITN _24222 -
Building Address: ,
oto 05 L PII -Z N
Owner'sName:
( 9'/'*iq CITY OF CUPERTIN0.6UILDINGDIVISION A A
re ane: LIc.NO APPLICATION / PERMIT
I'� U BUILDINGELECTRICAL-PLU\4BINC-MFiCHANICAL CATEGORY CONTROLM
Archite /Engines Lt o:
- - BUILDING PERMIT INFO
A
TY - ELECTRIC PERMIT - FEE - - -
PERMTISSUANCE ❑ ❑ ❑
LICF.NSEDC R OR'SDECLARATI N
Ihereb affirm that l am cemedunder provisions of Cha r9 commune- APPLIANCES-RESIDENTIAL
Y P Pte ( jOB DFSCRIPIION
[I...M1Section kine ofd tieon3o(t Buslnesand Profession Code,and my
license is in ful rte and tied. PANELS
Limn as, Lic. C(y \ ��� �aR Q
Date Contract �- ((,, v \/���
ARCHITE ECU 10 201-IODOAMPS
re Z I understand my plans shall be cord as pec c record.. OVER IODO AMPS SQ.FT.FLOOR AREA S/SQ.FT.
Fi odOE
Licensed Professional SIGNS ELECTRICAL
<cm. OWNER-BUILDER DECLARATION
u, SPECIAL CIRCUIT/MIBG
L, a ]herebyalRmnthatlam exemptfromthe Contractor's Llunse Law for the _
Z 9 following reason.(Section 7071.5,Business and Professions Code:Any dry or -
O TEMP.MEI'FR OR POLE]NST.
coun:ywhtre Informrequires pemdtloconmquirestheaImprove,demolfsh,or such aimittr
q 6 any structuretatements Lhat he e,aLw requ pursuant to the
revisions of to POWER DEVICES -
f5 U lite a signed statement that he 011censed pursuant m the provision of the
�3G Contractor's License law(Chapter9(commencing with Section 7000)ofDivi. SWIMMING POOL ELECTRIC
p�05 sion3aftholhuhessand Pro(esionsCode)orthathe6exempt thenefromand VALUATION
G the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHISFIXTURES
applirant fora permit subjects the applicant to a civil pe®Ity of not more than
r. o ' five hundred dollars($500).
I,as owner of the r NEW RESIDENTIAL ELECTRSQFT. STORIES TYPE CONSTRUCTION
Z ❑ e work,
a or my employees with wages r thele sole
compensation,0K Business
workandionthe s Code:
eh em intended oroffered(or
��O sale(Sec 7094,Bulinus and Profession Code:The Contractor's License Taw
deal not apply to an owner a property who build.or improves thereon,and OCC.GROUT' RFS.UNITS
who does such work himself orthrough his own employees,provided that such
improvements are not intended or offered for sale.I L however,the building or TOTAL:
improvement usold within one yearofcompletion,the owner-builderwill have
th,e_$nrden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
LL as owner of the property,am exclusively contracting with licensed 'FLOOD ZONE APN
mnmadmrs to controct the project(See.7019,Business and Profession Code: PERMIT ISSUANCE
The Contractors License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or impioves'thereon;and who contracts for such projects with a FEE SUMMARY
co,IlVLf(admr(a)licensed pursuant to the ContractorSecs License Law. BACK FIAWPROTfiCT.DLVICE OUTSIDE FEES
IJ I am exempt under B&P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANRARY Y N
Owner Date RECEIPT 0
.�' WORKMANCO PFSVSAZtNDECLARATION FIXTURES-PER TRAP SCHOOLTAX Y_ N_
01 hereby affirm that I ha e a corti ate of consent to self-Insure,or a RECEI f K
certi0cnteofWorkers'Compenatlonlnuranm ora artBld copylM1ertro((Sec. GAS M.SYSTEM.I INCAOUTLETS PARK FEE Y r N
-MM,Lab RECEIPT.
Policy I GAS EA.SYSTEM-OVER 4(EA)
BUILDING DI VI SION FE ES
rti ed copy v hereby furnished. GREASE WASTE INTFRCFPTOR PLANCHECK PEE
Certlfied copy V Blvd
with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA.20OFT. Date
RCCCI t#
(TMs lesson ned not be compldd Blhe permit bloc uric hundmd dollars
(St 00)oartily Ntifyth WATER HFATERW/VENT/ELECTR ENERGYFEE Y N
] at In the pedmu N
oanof the work forwch this permit is Issued,
1 shall not employ any person in any manner so as to become subject to the WATER SYSD]M/TREATIN'G
,Worker%Compensation Law/soff lifomla.Date PAID
Z Applicant lel Jy- NEw RESIDENTIAL PLMB. SQYT. Date ReCei t#
Z O NOTICE TO APPLI A .If,a making t his Certificate of Exemption,you
should become subject to the Workers'CompermaHon provsslom of the Labor TOTAL:
CCh Code,you must forthwith comply with such provision or this permit shall be - (( if I f 7 '�' UILDING FEE
jdeemed revoked. .
W 0 CONSTRUCTION LENDING AGENCY f/E •GO. SEISMIC FEE
CL I hereby afOrmthat there Is.crnsuudlon lendingagency lmrthe perform - TOTAL: �s� ELECTRIC FEE
Z ance of the work for vMhthbpermit is Issued(Sec.3097,Civ.C.I ,&.16
(� O Iendcr'.N.me - - - PLUMBING FEE
I— Ienaer.Aaarea QTY. MECHANICAUPERMIT ' FEE
O W Ianifythalha mat appHmtionandstatethattheabovemfor tion MECHANICAL FEE
a iscorresER
.I agree to complywith all city and county ordinances and statelaws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authotl represcntalivcs of thLi
F !A city to enter upon the above-mentiond property for Inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,indemnify an d keep harmles the City of Cupertino Date RlICeipt#
V against liabilities,pdgments,costs and expenses which may In any way accrue AIR HASIDLING UNIT(TO 10,IXI0 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit.
AIRHANDLINGUITf(OVFR10,000CR) CONSTRUCTION TAX
Signature of Applicant/Contractor Dam EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore building occopamt store or handle hazardous HEATING UNIT(TO 100,000 BTU) - Date Receipt#
materialas defined by the C pertlnm Municipal Code Chapter9.12andlhe
lle.lthamd SafctyCdr n25532(gt HEATINGUNIT(OVERIMNX)BTln TOTAL:
❑
Y. No
Willtheappliu I building occupant use equipment or devices VENTILATION FAN(SINGLE MID) ISSUANCE DATE
which cost ha>ardon Ir taminnU as defined by the Bay Arca Alr
Quality Marsagemient ,cot 7 BOILER-COMP OFI'DR 1W,IXq BTU) P A B P�
Yes No P1
have read the fiaz materials requirements under Chapter 6.95 of BOILER-COMP(OVQ2100,000 BTU)
the California Health& (sty Code,Sections 25505,75533 and 25539.1 1992
understandthatifthebuildingd..s m.rre tlyh.ve.tenanq that it is my NEW RESIDENTIAL MECIE SQ.FT. OCT :
responsibility to notify the occupant of the requirements which must be rust '
prior to issuance of a Certificate of Occopaney. CITY UIV 1 Ur �;Ur(D
roc authai agent Date ISSUED 6Y .J
TOTAL:
OFFICE COPY