22852 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
eu jd ing Address: 22852
11 6.2 i F Fo W'A e. C �,eT, N
s'ame: one: A A A
tt A
D6ki—S V. P L [� ' .S 96:286 CITY OF CUPERTINO-BUILDING DIVISION
on
Ctractor's Name:/ LIc.Ne: APPLICATION /PERMIT
Architect/Engl�r. ✓ Lic.N. BULDING-ELECTRICA4PLUMBINGMECHAMM
CAL CATEGORY CORO.X
QTY ELECTRICPERMIT FEE BUILDING PERMITINFO
Address: PL—Umbmh�ki
❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERNITTSSUANCE El
affirtnthat
der
I hereby irovlsn C9( rte APPLIANCES-RESIDENTIAL
ion7OOO)ofMvim3oftheBuenwandP /wsionsCoeandmy JOB D/FS.CR_E^rITOeN
licenseIs infull forceand effePANELS
LicenseCbro Li[.N -
�a
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
pQQyEu+0EoE I understand my plamahail be used as publicrecotds. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
<zU Licensed Professional SIGNS ELECTRICAL LED
I
OWNER-BULDER DECLARATION SPECIALCERCUT/MISC _
!❑� Ihereb !firm that l am exempt from the Contractors License Law for the i ��a
0 following reason.(Section 70715,Business and Prolwiuns Code:An d or f���,,,�-rrEll
r4o" +� countywhich requires a permit to constmct,alter,Improve,derrobeh,orrepalr limp.METER OR POLE INST. �� 8
q'V��.0 anystructure price to its boxance,akso requirestheappl)cans for such permit to / ��i/
g 3 file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES E L bbb Y a
W4 u, ContractorT
Contractors License Law 9(commencing with Section 7000)of DWI- /
f•f50.� akm3 ofthe Business and Pmfesaime Coda)orthat helsexempttherefromand SWIMMING POOL ELECTRIC VALUA'f10NO
Sn the basis for the alleged exemption. Any violation of Section 7071.5 by any
p applicant fora permit subjeenthe applicant to a civil penalty a not morethan OUTLETSSWITC1ffSFIXfURFS �^Z�_-
O. flu cad ed owner of the p%. NEW RESIDENTIAL ELECTR SQ.FT.
Z�n as owner ll the property,or n7 employers with wages as their sole STOW LS TYPE CONSTRUCTION
G &c.7MZpersationhN otheworkandthesC du ::Th oContendedoroffered eLfor
S sale(Sec. pply Bualnowand Profwions Code:The Contractor¢hremue law
S$ does oessuclytoan imser°fpropertyrough who builds
mporimprove,
ovided that such
OCC.GROUP RkS,UNITS
who
ovementsworkhimself edm muttered
hisowne.If.ho ea,p ,theb thatsuch
Improvements are not intended earofoo torsion,IL how er-b theerildingve TOTAL:
improvement uwld wlthmoneyearofcompletion,the owner-WBderw0l have
t4q_�+raenofpmving that he did not build or improve for purpose ofeale.). QTY PLUMBING PERMIT FEE FLOODZONE ApN
L1 L as owner of the property,am exclusively contracting with licensed
cors PERMIT ISSUANCE
ntractoto constrod the pmjed(Sec.7044,Business Professions Code:
The Contractor's License law does nor apply to an owner of property who
Wilda Or improves thereon,and who contracts for such p( ALTER-DRAIN&VENT.
ojects with a WATER(EA)
on
,,15Bfactor(s)Iluensed pursuant to the Contractors License Law, BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. 8 k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SA BY Y N
WORKMAN COMPENSATION DECLARATIONBBC=X
❑I hereby affirm that I have a certificate of consent to self-insure,or a FIXTURES PER TRAP SCHOOL TAX Y_ N_
arti(Icate of Worknri Compensation INunOtt on rertl(ied copythereof(Sec, RECEIPT M
3800,Lab C.) GAS EA.SYSTEM-lINCA OUTLETS PARK FEE Y N
Policy X
Ca3CGAS EA.SYSTEM-OVER 4(EA) RCE1pT If
unified copy Is hereby fumished. BUILDING DIVISIGN FEES
Certified copy is filed with the city Inspection division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE
(fhissedlunneed netbecompleted Rthepermit inforonehundroddollars SEWER-SAN[[ARY-STORM EA.2WFT. Date Recel t#
($100emlyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certify thato the person
onrenf thework a,to hthbpermitc burned,the
I Xhall not employ any pemwn In any manner ao a to become subject to the —
Workemi Compensation laws of California.Date WATER SYSTEM/TREATING PAID
Z Applicant
Z O NOUCETOAPPLICANT:"'after making this Certi(lcate of Exemptlon,you NEW RESIDENTIAL PLMB. SQFT, Date ReCel t#
F _ ahouldWcomn subject to the Workers'Compensation provisions ofthe Labor
C N .Code you must forthwith comply with such provisions orthb permit shall be TOTAL:
W > dcemrcd revoked. BUILDING FE
CL p CONSTRUCTION LENDING AGENCY SEISMIC FEE
M Z Ihembyaffirmthat there bamnstmctlon lendingagencyfortheperform-anceOftheworkforwhlchthls permit H issued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
U O Landers Nam PLUMBING FEE
LL 1- Lenders Aaareas QTY. MECHANICAL PERMIT FEE
O W I certifythat l hsvercadthb applicatlonand statethattheabove information MECHANICAL FEE
1 bcortect.I cgrato comply with a8 city and county ordinances and state laws PERMITISSUANCE FEES PAID:
N relating to building mvtrucilon,and herebyauthorlverepresentativesofthls
F U) city to enter upon the abovo-mentlonei property for inspection purposes, g/D
OR ADD TO MECH.
V — (We)agree to cave,Indemnify an a keep harmless the City o/CupertinoDate Receipt#
against liabilities,Jodgmenta,cons and expenses which may In any way arerueNDLING UNIT RO I0,ODO GEM) SUBTOTAL,
ago lint said City in mreequ he antingofthiapemmit.
NDWNG VN77(OVER 10,000CFM) CONSTRUCTION TAX
gesture of Applicant/COmndor DateST HGOD(W/DME CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrdousG UNIT CFO 100,000 BTL)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Date Recei t#
llealth and Safety Code Section 25532(a)? G UNIT(OVER 100,000 BTI)❑Yes . I)No TOTAL:Will the applicant orfuture Wild)ng occupant use equipment or devicesATION FAN(SINCLE RESID) ISSUANCE DATE
which emit harardous air contandrentsas defined bythe payAreaAirQuality Management District? -COMP QEE'GR 100,0(p BTU pR�Yus I�No 4-JUshave ad the harar�Ousmatcriab requirements under Chapter 6.95 of -COMP(OVER 100,000 BTU)the California Health k Safety Code,Sections 25505,25533and2S534. IU ����understand that if the building don not cOmently have a tenant,that it is myESIDFNTTALMECH. SQ.ET. OCTtZ �
i sponsibilily to notify the Occupant of the mqubements which must be met
prior to ksuance of a Certificate of Occupancy.
of fun?Itima
Owner or authorired agent Date
TOTAL: ISSUED BY:
OFFICE COPY