22618 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pru'en IdentificationPERMIT NO.
BWldin 22618
�ncrsarm: o e. A AL DA It
CITY OF CUP ERTINOBUILDING DIVISION �R
C aNa q it. a: APPLICATION /PERMIT `1
BUILDING-ELECTWCALPLUMBING-MECHANICI CATTLO BY CONTROL N
Arc Itect` nLk.Na: ,
QTY ELECTRIC PERMIT FEE PLUMB
LICENSED
INFO,
Address: I'FRMITISSUANCE bm: �/X Z� _ t y
UCENS EDCONTRACTOR'SunderDECLARATION I`�I JOB LIO
I hereby aHvmthat DiAsi am 3ofthe usines aiovo(Colons deandm APPI.IANCESRESIDENI'IAL JOB DESCRIPTION
ingwithosruehSection fiance (Dialect. (the Busimssand Pro(eulomCode,and my 'n ,, q�
license Is in tial force and Kfnet. PANELS g"G p�'eY/4}1
Date Class Conte 7
Date Contractor fsl/
ARCHITECT'S DECLARATION 201-1000 AMP"' � I `,�l
�
O'Z I understand my plan shall be used as public records. OVERIOOOAMPS f�QOR A�F.� _ $/SQ FT
���qqq-+++ D N
�j Licensed Professional SIGNS ELECTRICAL.
<y OWNEReBUILDER DECLARATION ! O T E
�n SPECIAL CIRCUIT/MISC
Z Iherebyaffirmthatlameaemptfrom the Contractor.License Law frn the R
Z O..'a following reason.(Section 70715,Business and ProfessionsCode:Any city or
O Z F y9nesa TEMP.METER OR POLE]NSI.
5 county whmph oritoits Brrmtame,altocoromqu,altheapmve,der3uch,er ttr /' `�. ��
any awcture prtement,that
he Is licensed
to the
provisions
of t e POWER DEVICES
k U file a signed statement that he V licensed pursuant to the proWlons of the
u, Contractor's License Law(Chaptsr9(commencing with Section 7000)of Owl.
Gra SWIMMING IY30L W.ECITt[C
..,,30:, Q the basis for
Businessand xampslon. Any
rthat lation is exempt thercfromana V_ ALUA]10N
pnbi Y.S?I the basis for the alleges exemthe a Any t violation of Section 701.5 by any / OUILETSSWITCHFSFIXTUI2FS /7VV`\m�JJ 1{ll\f
fivehundred
undredaollars $SM. sthc applicant tons civil penalty of not morethan /
N m live M1un s ownerlof theSOOT. NEWRINDENTIALELECTR
?G I,as owner Idol property,orhe employees with wages r their sole SQ'FL STOWFS TYPE CONSTRUCTION
compensation,w0ldothe work andthestacture is not intended or offered for
5 O s,le ISee 7044,Busiae and Pretensions Cade:The Contractors License Law
does not apply to an owner of property who builds or improves thereon,and
.00C.CROII' RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not intended oroffered for sale.I(however,thebuilding or TOTAL:
Improvement issold withinonerarofcompletion,theowner-bulklerwill have
It rd en of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FTAOU"LONE APN
EL,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constma the project(Sec.7044,Business and Professions Code: '�
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER IEA)
Wild, or Improve,thereon, and who contracts for such piojects with a FEE SUMMARY
gf1![acto(a)licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE
c i am exempt under See B k P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SAMTARY Y_ N
Owner Date RECEIPT'-
ECEIPT'X
WORKMAN COMPENSATION DECLARATION
E:]'hereby affirm that I have a certiffcete of consent to sell-lure,or is PER TRAP ll'Yl SCHOOLTAX Y N_
camiate of Workers Compensationlmurance ora certi(kd copythareof(Sec. uV RECEB'fN
Y�+7� �/ . GAS EA.SYSTEM-t INC.40UILRfs PARK FEE Y_
800,Lab 9 _ N_
Policy If �`//// (O RECEIPT X
Cumna an �d P- U GAS EA.SYSTEM-0VER4(FA) RECEIPT
cifcopyTs herebyfurnl, ed. GREASE/INDU57RL WASTE INTERCEPTOR
PLANCI-IECK PEE
F-1cenuiea ropy v rated with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FT. Date Recmi t#
(This se cion need not be completed tf the pernit is for om hundred dollars
(5100)rnlessJ WATER HEATQ2 w/VENT/ELECTR ENERGY FEE Y_ N_
I certify that lathe performanceof the work f tewhich this permB Is Issued,
I shall not employ any person In any manner so as to become subject to theWATER SYSTEM/TREATING
Workers'Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQFI. Date Recef t#
Z O NOTICE TO APPLICANT.If,after raking tho Certificate of Exemption,you
should become subject to the Workers'Compensation provi,tax of the Labor TOTAL:
Code,you must forthwith comply with such provisions or this permit shall be
W > deemed revoked. I BUILDING FEE -
CONSTRUCTION LENDING AGENCY SEISMIC FEE S.
CL Ihereby affirm thM there It a construction lending agency for the perfomm
Z TOTAL: ELECTRIC FEE
7 ,race of the work for wh�k1h�thhV rMt Lswed lSm.30ff7,CIN.CJ
U O Lender.Name /✓ons PLUMBING FEE
1- Lenders Address QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W ]mei.Iagm tocom comply
is with allcityndc ante Rha the urians s,a and
eaaws
L,correct.Isgreem comply with allcityhereby
aunty ice rapnee,and gate laws PERMIT ISSUANCE FEES PAID:
} N relating to enter
rupon t construction,entionherebyrtyor In repreaentanve ofthks
z city toen[erupon the above-mentioned property for Inspection purpose. ALTERORADD TO MFLH. Date Rxeipt#
� — (We)agree to save,lode d keep harmless the City of Cupertino AIR HANDLING UNIT CFM)
against liabi rer}ragmem eoataana ea wmmh raymanywayareroe SUBTOTAL:
agalnsts Ci a c the grand of this permit p1R l IANDUNG I-0VTT(OVER 10,MOCE) CONSTRUCTIONTAX
vtnaco,
f p /Contractor Date IXHAUSTHOOD(W/DUCT) 5 CONSTRUCTION TAX PAID:
M RDOUS MATERIALS DISCLOSURE
W .cant or future buildingt stare or handle havrdous HEATING UNTTHO 100,000 BTU)
noterulasdeMed bythe Cupertlno Municipal Code,Chapter 9.12,and the _ Date RMei t#
Health and Safety Cade Se 75532(,)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Ye I
Will the applicant or future bcilding occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havardous air cont, nants as defined by the Bay Area Air
Quality Management Dist n o BOILER-COMP pFN OR 100,000 BTU)
4 Yes
have read thehsa ous malcrlals requirements under Chapter 6.95 of BOREI2COMP(OVER1(D,000 BTL)
the California Health&Safety Code,Sections 25505,25533 and 25534. T
understand that iftM1 not cora tlyhave a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. f.i.t.tl C7
responsibi' ant a menta which most be rrct h�wnX�I
prirnt o tenroan I, f71u�flNaCw uIIQ
Owner or 'ud gent Data ISSUEDBY: Y�iYi6 w
TOTAL:
OFFICE COPY