22485 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Building w s7e*4) �oaA - 22485
�N rs ante: one. A A ATr
CITY OF CUPERTINO-BUILDING DIVISION ��2�I1
act.e.N Lic.N.: APPLICATION I PERMIT 1
BUILDING-ELECTRICAI.PLUMBING- CATEGORY CONTROL
rchit /En neer. LIc.Nm. MF-CHAMCAL
QTY!201-10DOAMPS
ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:�O 577 paJfel TISSUANCE � ❑ ❑
LICENSED CONTRACTOR'S DECLARATION X.
I her affirm that lam licensed under provblons.(Chapter 9(mmmmc- ANCESRESIDEN7fAL JOB DFSCRII'TION Te�N,L
Ing with Seaton 7000).(Division 3ofthe B..mr sand Professions Code,and my
IF
is
in N nd offect. S
Lkenu lass Lic.
Date Con__
ARCHITECT'S DEC ATION n0ZJ understand my plans shall be usd as public records ODO AMPS SQ.FT.FLOOR AREA $/e.Q.FT.
E o Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
k.. / Iherebyaflmrthat l am exempt from the Contractor.License Lawforthe SPECIAL CIRCNT/MLSC
9L following reason.(Section 70315,Business and Professions Code:Any city or TEMP.METER OR POLE INST.
F� c ntywhtchrequiresapemdltocomu cyalter,Impmve,de=Ush,ormpalr
anystrocturc prior to its Issuance,also requires the applicant for such permit to p POWER DEVICES`5 file a signed statement that he b Licensedpursuant to the provehms of the
Contractor's License Law(Chapter9(commanding with Section 7000)of
Divi- SWIMMING TOOL ELECTRIC -
O rim3.fthe Business and Profmalmo Code)orthat Nets exempt thomfromand VALUATION
the basis for the alleged exemption. Any applicant to acivi of Section net m by any _ _
the bent for apeaMted exe ption.the yvioation of
penalty not.5 rethan OUTLETSSWITCHESFIXTURFS
c. five,hundred dollars($500).
..�, ❑I,as owner of the property,or my employees with wages as their soleNEW RESIDENTIAL ELECTR SQFT. STORIES TYPE CONSTRUCTION
7< compensation,will do the work,and the structure b not intended or offered for
O sale(Sec.7044,Bustnsss and Professions Code:The Contractor's Lt..Law
does not apply to an owner of property who builds or improves thereon,and OC
whodoessuchworkhimeelforthrough hisownempl.yess,provided that such C.GROUP RES UNITS
Impmvemenb are not intended oroffered for sale.If,howmepthe Wilding or TOTAL:
Improvement b sold within one yearofcompletlon,the owner-builder will have
t"nien of proving that W did nor build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE EIppDZONE APN
L_J I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such projects with a
cq➢Vaam(a imnmdpumuanttotheCmtraci.rb Ltcen,se
L . BACK FLOW PROTECT.DEVICE FEE SUMMARY
L� fl
I am exempt under Sec. B&P C for this reason
OUTSIDE FITS
Owner DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
Date N
WORKMAN COMPENSATION DECLARATION RECEB'T
❑1 hereby affirm that I have a certlBrate of consent to sell-Inwre,oraMnRF,S PER TRAP _�J SCIi00L-TAX Y_ N_
3 hiflhbof Worker%Compevtimil mnmoraadifkdmpythemof(Sec. GAS FA.�,�.�-1 WC.40UTLETS RECEPT
Polity# ��0����-- / / PARK FEE Y_ N_
CoCertGASYSTMVER (F ) REGM'T
famished BUILDING copy b hereby fi . DIVa
I510\FEEB
❑Certifaed copy b filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETRAP PAID Jog-
COMPENSATION INSURANCE
(Thbsectlon need net becompiaed iftheper at.(oras hundred dollars SEWER-SANITARY-STORM EA.20OFT. Date Refel til
(8100omless.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I ll nor employ
o the performance.(the work for which this permit c bored,
I shall not employ any person In any manner m v to become aabjca to the
Workers'Compensatlon hors of California. ATER SYSTP.M/TREATING la.Date PAID
Z Applicant
Z ONOTICE TO APPLICANT:It, RESIDENTIAL making this Certificate of Exemption,you NEW RDENTIAL PLMB. SQFL Date Reoei tli
should become subject to the Workers'ComperwUon provision of the Labor
W Cde,you must forthwith comply with such provbm
borthia permit shall be TOTAL:
W > deemed revoked. BUILDING FEEQ7
a p CONSTRUCTION LENDING AGENCif SEISMIC FEE
I hereby affirm that there ba nom uction lending agency forthe perform-
Oante of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
O _ Leder's Name PLUMBING FEE
LL I— I.ender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1 certifythatl have read thbapp0ationand state thattheabove Information bmneRlagmetocomplywith alldtyand countyadlnaecesand state laws PERMIT ISSUANCE FEES PAID:
T N relating to building construction,and hereby authmbe representatives of this
F Z city to enter upon the abovcmeNloned property for inspection purposes. ALTERORADDTOMECH.,
(We)agree to save,ledeharmless/y an d keep harmless the City of Cu pert Inca Date Receipt#
against liabilities, costs and expenses which may in any way accrue AIR HANDLING UNIT UO To,000 CFM)
aga Inst said City In c...eq.once a grant ing of this permit.
�z 9 SUBTOTAL.
HANDLING CONSTRUCTIONTAX
St atut pplicant/Q otra r Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARD IATERIALS DISCLOSURE
W he appOmtor foto u0d.g occupant store or handle haeardous HEATING UNIT CM l00,ODO e-IU)
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the Date Revel tN
Health and Safety Code Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes M No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haurdous air contaminants as defined by the Bay Area Alr
Quality Management District? BOILER-COMP OHF OR 100,0(0 BTU) PISA 4
Yes ❑❑No
have read the ba>allo. materials requirements under Chapter 6.95 of MOILER-COMP 100,000 BTU)
the California Health&Safety Code,Sealons 75505,25$33 and 25534.1
understand that if the building does not cvrmn0y have a tenant,that it b my NEWRESIDFNTIALMECH. SQFT N�
responsibllkytonoulyth ompant.fthe requlrerrentswhicM1 must be met
judo Issuance ofaCrll(f eofOcevpanry.
7zz9 FS
r or authmice. Date
TOTAL: ISSUED BY
OFFICE COPY