22789 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERM TNO.
Building Address: ' I ^/1 (� �'!
l tiD R GG 1j, 9
� .r1J6n�er,�sI, m1as,/:� one: p A
1. — CITY OF CUPERTINO-BUILDING DIVISION
C ct isCNa�me': �+ Gc No:
APPLICATION /PERMIT
577 BUILDINGELECTRICALPLUMBINC-MLCHAMCAL CATEGORY CONTROLN
it En Lk.No:
5- R
CITY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address — PERMITISSUANCE
LICENSED CONTRACTOR'S DF. LARATION
I hereby affirm that l am licensed under provisions of ChaP<erg(comment APPLIANCESRESIDEMIAL
JOB DESC�oN
ingwith Section 7000)of Division 3 ofthe'B'e3si ssand PrefessionsCods,and my
Ii=
is in/u roe and effect. I PANELS K7.
Lice. lam LIc.N `` ,,
Date Coninctor r• UP TO 200AMPS
ARCHITECT'S DECLARATION 20140DOAMlS
Pggq± Z I understand my plans shah be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
00
fill�j Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
A L E D
[hereby a( m that]ass exempt(romlhe Contractor's License Law for the SPECIALCIRC[IT/MLSC NPUT
Co E
following reason.(Section 70.715,Business and Professions Code:Anydty or TAMP METER OR POLE INST.
p county which requlresa permit tomnstruM alter,linpmve,demolish,oreepair
anystmMmpriortolts ance,al ro luirestheappbantforsuchpermitto )EWER DEVICES
p; n, file a signed statement that he is Licensed pursuant to the provisions of the — DATE
Ela m0� Cont."r'sLicense Law(Chapter 9(commintng with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUA
H,� � sion 3ofthe Businessand Professions Code)orthat heis exempt therefromand _2 TIOY�
q ALUA
G$p7 the basis for the alleged exemption. Any violation of Section 7031.5 by any, OUTLETSSWITCHESFTXTUFES
<$ applicant for a permit subjects the a pplicant to a civil penalty of not more than
a five hundred delta.(S5D0). NEW RESIDENTIAL ELECTR
�n ❑I,as owner of the property, SQFT. STORIES TYPE CONSTRUCTION'
p ork,a or he employees with wage as thele sole
.1.(Scomp" s 70K willdoe,.the work icklemstructvre Vnotntended oroffered(or
��O Bile(Sec 7014,Business aeW[Rufessions Code:The Conhactols License Taw
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
ortheaugh hisownemployees,provided that such
Improvements are not Intended oroffered for sale.IL however,thebuilding or TOT4.
Improvement issold within one yearofcompletion,the owner-builder will have
til,¢+rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING:PERMIT. FEE FLOOD ZONE APN
"L as owner of the property,am exclusively contracting with licensedPERMIT ISSUANCE
contractors to conswct the project(Sec.7044,euslne.and Pro(essloro Code:
The Cont.ctor's License Law does net apply to an owner of property who
Wilds or contracts Improves thereon, and who nor such p�ojev with &VENT-WATER(EA)
p. h a FEE SUMMARY
cq➢!jIm exempt
dnder SttotheContnctolsLicenx Law. BACK FLOW PROTECT.DEVICE
U I am exempt under Sm B&P C for this ncasan
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N—
Pvder Date RECEPI'N
r WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCFICOL TAX Y— N—
❑Ihereby affirm that 1 have a certificate of consent to self-Insure,or a AECEII'T N
cerc0,Lab C.)iflcateof Worker.'Compen tit Tre ranmora.Aiftedmpythereof(Sec.
380GAS EA.SYSTEM-1 INCA 0UTLE15 PARK FEE Y N
—
R
Paltry a ECEITT NGAS EA.SYSPEd-OVER 4(EA)Com any - BUILDING DIVISION FEES
�C ied copy ta herebyfurnished.the cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Jed copy V(FIN with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.2(0F1'. Date Recei t#
(Thissedion need net be completed if the permit E for one hundred dollar
($lMorless.) WATER HEATER w/VENT/ELECTR ENERGY FEE Y— N-
1 certmce
certify that in the perforanof the work for which this permit Is issued,
I shall not employ any person it,any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
O Z Applicant NEW RFS DENT ALP Me. SQ F7. Dale Reeei Il
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workem''Compsmatmn provisions Orme Labor TOTAL:
~ N Code, must forthwith comply with such rovlslons orthb permit shall be
LU j deemed Code,you
PY p BUILDING FEE
Il.l ' CONSTRUCTION LENDING AGENCY - SEISMIC FEE •CD
CL F3 I herebyaffirmthat there is a construction Icedingagency forthe perform- TOTAL". ELECTRIC FEE
Z sure of the work for which this permit la Issued(See.309],Civ.Q
(� O lenders Name PLUMBING FEE
LL ~ LendersAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U I certify that l have read this applicatio...d sate that theabove ln(ormatles �aN
O W Is correct.I agree to comply with all city and county ordinancesand state laws I PERMIT ISSUANCE (y FEES PAID:
} �' relating to building construction,and hereby authotlu representatives of this
hZ city to enter upon the above.hnmtioned property for Inspection purposes. ALTERORADDTOMECH. / Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cu perdho
V agai tb' ties,jud mks and expenses which may in any wayacceue AIR HANDLING UNIT CFO 10,000CFM) SUBTOTAL:
a ins 1 u nee of the granting of this emit.
n AIR HANDLING UNIT(OVER 10,(XOCTM) CONSTRUCTION TAX
Sinsture of Ap 'ant ontnctor l• I , EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
DOUSMATERIALSDISCL SURE
Will the applicant or future building occupant storeor handle h.rdous HEATING UNIT ITO 100,000 BM Date Recei t#
material as defined by the Cupertino Municipal Ccde,Chapter9.lZandthe - —
Plealth and SafetyCode Section 25532(-)1 HEATING UNIT(OVER 100,000 BTU) TOTA
❑Yes N No —
Willtheapplicantorfuture building occupant use equipment ordevicee VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air.
®
Qua Iity Ma nagement Dist rlct7 - BOILER-COMP OHP OR 100,000 BTU)
El Yes ❑❑No
Thavereadtheha,! ousnuteriaisrequimwnbunderChapter6.95of BOILER-COMP(OVERiK000BTU)
the California Health&Safety Code,Sections 255(L5,25533 and 2 M.1
understand that if the building does not mrrcntly have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT
responsibility,to notify the occupant of the requirements which must be met p q
prior to issuance of a Certificate of OcmpanryF
.• �r 4 ')Q�
Owner or authorised agent Date. Iv
TOTAL-j Axd n
OFFICE COPY