22438 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY a
Building Protect identification PERMIT NO.
Bunding'Address: N 22438
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� f� B'4 �Lfllll I�7J J�-3� CITY OF CUPERTIN4BUILDING DIVISION
entraaor'aNam : ue.Nc: APPLICATION I PERMIT Z ( )
1 - CATEGORY CONTROLN
BUILDING-ELECTRICALI'LIIMBINGhfECHANICAL
t � A ItM/Engineer. Lk.No: '
'QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PFRMITISSUANCE Z.00 ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby Sacti lrmthatl am Rcensefthe Bu nems dPmfes pmsr9de,and nc- APPLIANCES-RESIDENTIAL JOB DESCRD'fION,
inlicensei In fen forceofdoffieon3ofthe8usinessandlaralessions Code,and my
Livens plass foram and effect PANELS _
Data G ARCHITECTS
r 1 X11-1000 AMPS
ARCHITECTS DECLARATION
pq+
9
0 ZO I understand my plan shag be used as public records. OVER 1000 AMPS SQ.FI.FLOOR AREA 5/SQ.FT.
Licensed Professional SIGNSELECTRICAL /
Q w - OWNER-BUILDER DECLARATION - I ,n
re Thereby SPECIALCIRCL(T/MISC I� II vJ
71.., afRrm that l am exempt from the Contractor's License Law for the -
following reason.(Section 7071.5,Business and Professions Code:Any city or
OMF., TEMP.METER OR POLE INST.
C5a county which requiresa pemdttoms,reel irestheapmvgdemolkh,or repair
I� anya suaure prior entsha he is licensed Iniesua t to Chet provisionorsuch of
a POWER DEVICES r}
file a signed statement that he h licensed pursuant to the pons 700) of the l /
Contractor's License Law(Cha pkr9(rommenan with Section 7000)o(Divl-
Q3 In Bw SWIMMING IDOL ELECTRIC Uh
SOS son3oltheBusine eged a rofessicat. An violation
hi ofSxemp thercfromany I ALUADON
S" the bash for the alleged exemption. Any vlolatlon of Seaton 707L5 by any OUTLETS-SWITCHES-FIXTURES
pp1. nifora per mit aubjectetheapplicanitoacivil penalty olna nnrethan
r, OQ fiv Bred dollars($500. + EQFf. STORIES TYPE CONSTRUCTION
NEW RLSIDFNIIAL ELFGTR
G7 as owner of the property,or my employees with wages a Their sole
�7. m(Sec.7 on,willclothe KBusiness and k.and thest ucture ode:Thn a IntendedContactor oroffered
s,Law
O sale(Sec 7044,to an owner of propePoxfouslonrty
Code:The or improves
ldcewelaw
$$
doss not apply roan owner olpropertywho Wilda orimprovesthereon,and OCC.CROUP RES.UNITS
whodoessuchwork himse8orthrough hisown employees,provided thatsuch
Improvements are not intended oroffered!weak.If,however,thebuiiding or TOTAL: s�
improvement is sold within one yearof completion,the owner-builderwlll have
ti ffiraen of proving that he am not bund or improve for purpose of sale.). QTY, PLUMBINGPERMIT FEC FLOODZONE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Profession Code:
The COntnctore License Law does not apply to an owner of property,who
Wilds or improves thereon, and who contracts for such projects with a ALTER-DRAIN&VENT-WATER MA) .
yy.t,raaor(s)licensed pun pito the Contractor.License Law. FEE SUMMARY
IJ 1 am exempt under ec. B k P C for this maven BACK FLOW PROTECT.DEVICE OUTSIDE ITTS
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N
Owner Dat - RECEB'Ta
VORKM Ih SATION D[CLARA O .1.U�S PER TRAP SG{OOL 7A% Y— N—
❑i hereby affirm that)have o certificate of consent to copy
ora RFCFRu'T M
certificate of Worken'Compeaatlon Insurance oracertified ropy thereO!(Sec.ISM, GAS EA.SYSTEM-1 INCAOUTLE15 PARK FEE Y N
Poll Lab CJ —
Policy p DING DI M
CAS FA.SYSIpf-0VER 4(FA)
Cam any BUILDING DI VISION FEES
ECertified copy h hereby th the city
d. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
E3 Certified ropy h(sled with the dty inspection division.
CERTIFICATE OF ID(EMPIION FROM WORKERS' GREASETRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARY-STORM EA.200hT. 'DBIC Recei III
Clhissection need not be completed if the permlt is!crone hundred deltan
(5100°`less') wnrFR FIFAITR w/vENT/ELECTR ENERGY FEE Y N
I certh Is
ifythat in the performance of the work for which this permit sued, —
I shall not employ any person in any manner n as to became subject to the WA.fFR SYSTEM/TREATING
Workers Compensation Iawsof Californh. Date PAID
-
zZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z O NOUCETO MPLICANT:U,after makingthis Certlflcateofacroption,you
should beroms eubpet to the Worker'COmpensation provisions of the Labor TOTAL:
CC CC N Code,you at forthwith comply withsuch provhloaorthh permit shall be
j deemed revoked,
BUILDING�E
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby afnrmthat there is a rowtruaim lendlogagency for the perform- TOTAL: ELECTRIC FEE UD
D Z ance of the work for which this permit h Issued(Sec.3097,Civ.C.)
OO Lender's Names PLUMBING FEE
LL F (.enders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U IceAi"atlhavercadthlsappbmtionandmatethattheaboveinformation
O W isco ect.Iagree to comply with all city and county ordinances and statelaws PERMIT ISSUANCE FEES PAID:'
C relating tobWlding romtmctfon,and hereby authorize representatives of this
F W city to enter upon the abovementioad property for inspection purposes. ALTER ORADD TOMECH.-
Z (We)agree to save,Indemnify an d keep harmless the City of Cu pert Ino Date RCCeipt#I
O against liabilities,End ments,costs and expenses which may In anyway accrue AIRHANDLINCUNIT(TOt0,0t10CPM) SUBTOTAL:
aga said City said City i�n��ofthe grant g this permitgrand g this permit.
_( AIRHANDUNGUNTE(OVER10,000CIM) CONSTRUCTION TAX
`l CONSTRUCTION TAX PAID:
ontnaor at IXHAUSTHOOD(W/DUCT)
RDOUSMATERIALS SCLOSURESCLOSURE
Will thea lion or future building occu an rtorc or handle hazardous HEATING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date RCcei t#
Ilealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100000 BTU) - TOTAL: OV
❑Yee [iJ1 No
Will the applicant orfuture b,ilding occupant use equipment or devices VWFIIATION FAN(SINGLE BESIDE ISSUJIpIC.d1�1L'�ATE
which emit havrdous air contaminants as defined by the Bay Area Air `w
Quality Management District? BDILER-COMP OHPOR 100,000 BTU)
Yes Q No Im
IEavemad the h.Vousmaterials requirementiunderChapkr6.95of BOILER-COMP(OVER 100.000 BTU) WL Rf$,
a the California Health A Safety Code,Sections 25505,2SM3 and 25534. I Y�J f�
1. understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ_FT.
responsibility to notify the occupant of the requirements which most be met ss��j(��ssa�
prior to Issuance 0 a Certificate of Occupancy. Nati-IN.
/AI \
Owner or authorized agent Data TOTAL: ISSUEDBY, t
OFFICE COPY