22098APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Buildin Pra ed IdentlllueanPERMITNO.
B.2- Address: 004 �4 �
22098
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CITY OF CUPERTIN0.6UILDINC DIVISION
APPLICATION / PERMIT
BUR. DINGELECTRICALPLUMBINGM HAMCAL
.
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G°^ ° '•"'^•° u= "°
%�'/'-^-+ -2,
CATEGORY
CONTROL #
ArchltM/Engin=es Llc. No:
QTY ELECTRIC PERM IT FEE
BUILDING PERMIT INFO
-
Address
❑ ❑ ❑
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Bcenxd under provbionaofChapter 9(commenc-
ingwith Section 7000).! Division 3 ofthe Busineasand ProfeslonsCode, and my
Bronx la in to !orae and elect.
License Clas Llc. X '1 SZ 9 % S
Date ContraRor,,p��/• — 6 - p
ARCHITECI'SDECLARATION
I understand my phv ehaB be used ss public mmrds
Licensed Professional
OWNER -BUILDER DECLARATION
IherebyafBrm that l am exempt fromthe Contnctor.Llcenselawfothe—ClaN
following reason.(Section 7031.5, Business and Professions Code: Any city or
county which requires a permit no construct, altep improve, demolish, or repair
anygructure prior to its lanoince,as.require. theapplicant forouch permit to
Elle a signed statement that he is licensed pursuant to the provisions of the
Comrsnoes License Law (Chapter 9 (commencing with Section 7000) of Dlvi-
ghn3 ofthe Butl m•and Profemloru Code)orthathebexemp"herefmmand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
appllcantforapermitaubjedetheappBcanttoadvilpe®ltyofnotm mthan
five hundred dollars (SSM.
F1 1, as owner or the property, or my employees with wages a•their sole
compensation, wW Bothe work and thegmdurc b noHntended ser otfemd for
sale (notap applyto ane.aandfpropety Cade:The orimprve, Lerear, Law
whoanotapply loanownerofpropertywhobuildsla ImprovelhereoRand
whodoessuch
mrn MmxBorthrough Msownemplhcwoprovidedthatsuch
Improvement.arenotintended
eats am
Improvement .sold withinarcyearnfcompletorythchwner-W BderwW have
earofc pleia.tLhowever,th#Wildingve
tlELIrrden of proving that he did not build or improve for purpose ofsaled.
U L as owner of the properly, am exclusively contracting with licensed
contractors to comtroct the project (Sm 7046, Business and Professiors Code:
The Conlneor's License Lw does not apply to an owner of property who
Wilda or Improve. thereon, and who contracts for such piojects with a
c actor(s)licensed pursuant to the Contractor's Llcenx Law.
LJ I am exrmpt under Sec B k P C for this resahn
APFLIANCES-RESIDENTIAL
JOB DF IUFI ION
V`7 I
PANELS
2DOAhVS
pUP 01
OVERIODOAMPS
SQ. FT. FLOOR AREA
L E D I N
P U T E R
pppp yyy
L.Y
f/SQ.FT.
SIGNSELECTRICAL_
SPECIALCIRCUfT/MISC
TEMP. METER OR SOLE INST.
_
POWER DEVICES
SWBPUBNG POOL ELECTRIC
OUILE7SSWITCF{FSFIXTURFS
VALUATION/
NEW RESIDENTIAL ELELTR SQ.F7.
STORIES
TYPECONSIRUCTION
TOTAL:
QTY. PLUMBING PERMIT FEE
OCC.GROUT+
RES. UNITS
PERMIT ISSUANCE
FLOOD ZONE
APN
ALTER -DRAIN kVENT- WATER (EA]
FEE SUMMARY
BACK FLOW PROTECT. DEVICE
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES, PER TRAP
SANITARY Y_ N_
RECEIPT N
Owner Date
WORKMAN COMPENSATION DECLARATION
❑ I hereby affirm that I have • certl0cate of consent to sett -Inoue, ora
¢slficat fWorken'Compewtihnlrcursnce hrsoertifkd ropy thermfLec.
3800, lab C.j �,
SCHOOL TAX Y_ N_
RECEIPT #
GAS EA. SYSTEM -1 INCAOUTLETS
PARKFEE Y N
GAS EA. SYSTEM -OVER <(EA)
BUILDING DIVISION FEES
[PCesified copy i. hercbyt.
CertVied ropy to filed withthe
ry I he city inspection division.
CERTIHCATEOFIXEMPTION FROM WORKERS'
COMPENSlmI INSURANCE
(Thisaeatihn need sol be completed If ifs the permit b (Drone hundred dollar
(f10 undilys0
I mnot emplhat oy anyhe eo on in any manner forwhkh conthis permit is booed,
I shall not employ any person In any manner eo u to become subject to the
Applicant s' Compensation laws of California. Date
Applicant
NOTICETOAPPLIGM:IL after making this .t In. provisions
.(ons oft the
ns or this p ofthe Labor
Chou,becomsubjectitthe ply with such
Cade, you must forthwith comply with such provblhru or this permit shall be
decnr•d revoked.
CONSTRUCTION LENDING AGENCY
I hereby afBrtn that there is a construction leading agency for the perform
ance of the work for which this permit is issued (See. 3097, Civ. C.)
seLoor eaa as
Imrtilythat l luvereadthisapplicationand statelhatthe above Information
is correct. I agree to comply with all cityand county ordinances and gate laws
relating to building construction, and hereby authorize representatives of this
city to enter upon the abovcmentbned property for Inspection purpose.
(We) agree to save, indemnify an a keep harmless the City of Cupertino
agairuthabllltlee,' menta, cogande :mcawhLchrmy Inanyway.mrm
against a roneryuen ft granting AoR-h-ls_perm�lL
rL,f'✓ �%
Sig .(App lent/ ontracthr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or ionize building occupant store or handle hazardous
material as defined by the Cupertino Municipal Code, Chapter 9.1 Z and the
Iiralthand Safety Cod r2AIctihn 2SS32(a)i
I—I Yes, applicary� No
Bemt hasardntor suremiaing occupant useequipmentdevices
which eMahazardousair rict? rats as defined by the Bay Arca Alr
ay Area
Quality Management DkMci7
I Yes -M No
20305,23533 and 255ro,95°(
have ad the nia I ealth& emrtde, ls Sections
the Code,notcurently have .tend, that I
ersta dthat If the building that Itis my
understand that if tifl"he nocu ocs not the
have which
responsibility to nosily the ompa rat of the requlrcmenta which swot be mg
prior to issuance of a r_eDlflicx�e of Omrpanry.
CREASE/INDUSTRLWASIEINTERCEPTOR
LA
PNCHECKFEE
PAID
Date RCCeI til
GREASETRAP
SEWER-SANITARY-STGRM EA 200FI
WATER HEATER W/VENT/ELECTR ba
' ��/
ENERGYFEE Y N
PAID
Date Recei O
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB._SQ.67.
TOTAL:
BUILDING FEE
SEISMIC FEE
TOTAL;
r�
ELECTRIC FEE
QTY. MECHANICAL PERMIT FEE
PLUMBING PEE
MECHANICAL FEE
PERMIT ISSUANCE
FEES PAID:
ALTER OR ADD TO MECH.
Date Reed tft
00
AIRHANDUNGUNIT(TOI0,0CFM)
SUBTOTAL'
AIR HANDLING UNIT (OVER IQ000CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DIX:p
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,041 BTU)
-
Date Recd t#
HEATING UNIT (OVER 100,OOD BTU)
TOTAL;
VFNDLATION FAN (SINGLE RESID)
ISSUANCE DATE
A
Sj
IJN
�/IQ
d
DTZ ca
ISSUED B V
IIED
BOILER -COMP OFB+OR 100,000 BTU)
BOILER -COMP (01101100,000 BN)
NEW RESIDENTIAL MECH. $0,17.
ocrorauthorizedsgret Date
V
OFFICE COPY