22104 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Pro'e I Identification PERMIT NO.
BuOding Addreo:
10,40 v` c r , tT 22104
ners a VV—on�e;/�
1 S 4 ��j� 7� CITY OF CUPERTINO-BUILDING DIVISIONContractor's Name: Lie.No: APPLICATION I PERMIT 1
BUILDING-ELECTRICAUPLUMB[Nr MECHANICAL CATEGORY CONTROL M
ArchltM/Engineer. Lk.No;
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add..
LICENSED CONTRACTOR'S DECLARATION PERMITISSUANCE ❑ ❑ ❑
I hereby affirmthat l am licensed under provisions o(Chapter9(commm APPLIANCES-RESIDENTIAL JOB DESCRB'IION
IngwithSection 7000)of Dlvlslon3ofthe Bufnessand Pm(easlonsCode,and my
wLPa )OWS
Ilcense Is In full force and fleet. PANELS
License Cho LIc.N
Date Contractor UP TO 2DOAMPS
ARCHITECT'S DECLARATION - 301-1000 AMPS
q�+a0u�7'
I understand my plana shall be used as public records.+ OVFRIOWAMPS �T^O 35 RE�RrA ' f/SQ.Fr. '
Fi z�j Licensed Professional SIGNSELECTRICAL M P:'
T
<<�Q OWNER-BUILDER DECLARATION SPPGIALCIRCNT/MISC
L., I hereby affirm that l am exemptfromthe Contractor's License Law for the
O q follawisg reoon.(Section 7e31S,Businessland Professions Code:Any tlty ar A 'a9 ,
FZI"cy montywhich requires a permit to mostruct,alter,Improve,demolish,areepair T'EMP.METER ORPOLE INST. E. g/
S� 3 anystmu mpdortolte Wuance,alsorryuimslheappBant(o mchpemdtto
P ruE his,a signed statement that he is licensed pursuant to the provision of the POWER DEVICES
3µ Cuntrsoors License Law(Chapter9(coevnentlng with Section 7000)of Divi- SWUIMING POOL ELECTRIC VALUATION
HBO s1se3ofthe BusNesaed ProfeobmCode)orthat hehexemptm
therefroand
0 S the basis for the alleged exemption. Any violation of Section 70315 by any OUILE1SSW[TCHESFIXIURFS
applicant fora permit subjects the applicant toll civil penalty of not morcthan
I R S fivn i,as o nerdolof the po NEW RESIDENTIALELECTR SQFI. STORIES TYPE CONSTRUCTION
�s ❑compensation,a owner ll list property,or he eumme in with wages r their sole
O01.(Sc0K wllldothe work andthertmcturc hent Intended or coffered for
ole not apply
to alnow and f property
who
lds C improves License Law
$
does not apply torn owmrorproperty who buildsor Improvethereon,and
F3^ whodoeaeuch work hlmeel(orthraughhis own employees,provided that such OCC.GROIRsRES.UNITS
Improvements arenas Intended proffered for sah.If,howevegthe building or TOTAL:
improvementbsold withlnoneyearolcompletion,thc owner-budderwlll have
rdenof proving that he did not build or bnprove for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD PONE APN
ae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
tractors to construct the project(Sec.7044,Business and Profeolom Code:
The Conductor's License law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
Wilds or Improves thereon,and who contracts for such p(ojects with a - - FEE SUMMARY
on
licensed pursuant to the Conhadols License Law. BACK FLOW PROTECT.DEVICE
1_l l am exempt under Sec. B k P C for this moron
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner DataRECEIPT=
WORKMAN COMPLTISATION DECWRATION S PER TRAP SCHOOL TAX Y N
❑I herelry affirm That 1 have a certlftrate a!consent to eel(-insure,ora FIXTURERECEIPT N
mnlRraleo(WorMeri CompematlonIssuance ora certl(Icd mpythereof(Sec.
3500,Lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Pdiry M DING Df M
Com an GAS EA.y BUILDING DIVISION FEES
Certified copy b hereby dwith the
ad.city CREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECK FEE
CertBled copy h Ilkd with the tlty inspection division.
CERTIFICATE OF EXEM PrION FROM WORK ERS' GRFASETRAP PAID
COMPENSATION INSUn,isfo SEWER-SANTTARYSIORM EA 200FT' Date Remi tM
(worless.) need cad becompifed If the perrtdt hforone hundred doltan P
(8100rrifytJ WATER HEATER W/VENT/ELECTR ENERGY FEE Y N—
I
ll not emplhat oy
any pershe on
In annce tmannerhework for to b corn ertNt b ho the
I shall not employ any perms In any canner at u to become wb)M m the
Workeri Compenollon Laws WATER SYSTEM/TREATING wa of California.Date PAID
—
Z Z Applicant
NEW RESIDENTIAL PLMB._SQFT. Date Remi til
P: O NOlicant AI'['LICANT:U,after making this Certificate o(Exemptlmn,you
should become subjM to the Workers'Compensation provisions of the Labor TOTAL:
= N Code,you at forthwith comply with such pruvisims,or this perout shall be BUILDING L
LU > deemed revoked. -
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE O
I bemby affirm that there h a construction lending agency far the perform- ELECTRIC FEE
anre of the work!or which this permit h Issued(Ste.3097,Civ,C.) TOTAL:
Larder.Name PLUMBING FEE
.IL Lcoder's Address - QTY. MECHANICAL PERMIT FTE MECHANICAL FEE
OW Icertifythat l have read thisappBntlonand state that theabove information
4 B,crowt.I agree to comply with all city and county ordinances and elate laws PERMITISSUANCE FEESYAID:
r relating to building construction,and hereby authorise representatives of this
Fcity to enter upon the above-mentioned bove- tioned property for inspection purposes. ALTFRORADDTOMECH.
2
— (We)agree to save,Indemnify an d keep harmless the City of Cu pertleo Date Recei Ip
agalmtllablli ea,jud no"cmNeand expenses which rtuy In anywayattroe AIR HANDLING UNIT Q010,000 CFM) SUBTOTAL:
agaWt old tyro sego;nm of the gra sting o(thle permit. AIR HANDLING UNIT(OVER 10,ODOCFM) CONSTRUCTION TAX
Signature of Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE '
Wlllth
not
or future building occupant store or handle hazardous HEATING UNIT CID 100,000 BTU) Date RCCeI t�
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ifrallh and Safety Code SMI=25532(a)I HEATING UNIT(OVER 1DO,"BTI!) TOTAL: �v
❑ Yes No
Will the applicant procure building occupant use equipment or devices VENTILATIONFAN(SINGLERESID) SUARCE DATE
which emit hazardous air contamimnb as defined by the Bay Area Air n 1
Lu�lily Management Disrict2 BOILER-COMP OHPOR 100,000 BTU)
7 Yes �1 No
have read the hazer nus rulerlais rnquiremcnh under Chapter 6.95 of BOILER-COMP(OV[R 100,000 BTU) MAY �pa1i
the California Health h SafetyCode,Sectims,25505,25533 and 25534.1
understand that lflhe building does not currently have a tenant,that It is my NEW RESIDENTIAL MEIN. SQ.FT.
responsibility to nai the panto(the requirements which moat be met
prior la issuance CertIf 6fOttvpanry. aa.ZZiiTh 4�V
Owner or awhori agent
Data ISSUEDBY: �a UI✓B'PL
TOTAL:
OFFICE COPY