22141 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO,
Build ing Address: 22141
p one: A B A A
K 'ZS3 325 CITY OF CUPERTINO-BUILDING DIVISION �
TE
ContractorsName: Lic.Nce APPLICATION / 5
PERMIT -g.91
�. BUILDING-=TRICALPLUMBING-MECHANICAL CATEGORY COMAOLN
Architect/Engineer. Lk.No:
QTY ELECTRICPERMFr ^FEE BUILDING PERMIT INFO '
Address: PERMITISSUANCE v�
LICENSED CONTRACTOR'S DECLARATION 1:1 IJ ,
I hereby affirm that l am Lecrand under provisions of Chapter 9(commenc- APPLIANCESRESIDENTIALJOB DFSCRII-HON
ingwlth5e ion A100)of DiAMon3ofthe Buslnessand Professions CDdgand my
liana Is In full force and aIle#. PANELS
`
Class
Date
Date —Contractor UP TO 200 AMPS
ARCHITECTS DECLARATION 1201.10DO AMPS
0Z Iundontand my plans shall be,used as publicrecords. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
Wcv OFj Licensed Professional SIGNSELECTRICAL
L -
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/ML97 1
Z f'. Zi Iherebyalfirm that l am exempt from the Contractor's License Law for the
G2
following reason.(Section 7031.5,Business and Professions Code:Any city or
O Z F: TEMP.METER OR POLE INST.
P� cmntywhlch re quires a permit torovtvct,alter,Improve,demolish,orespair
< anystmc mpriortoltstssaance,alsorequlmtheappbranlforsuchpermltto POWER DEVICES
file.signed statement that he is licensed pursuant to the provisions of the
�ggSOO
u. Contractor's License Law(Chapter 9(commencin with Section 7000)of DTvi-
F�O5 gong ofthe Business and Professlois Code)orthatt he he eempttherefromand SWIMMING POOL ELECTRIC VAD0WqN
the basis for the alleged exemption. Any violation of Section 7031.5 by any /Q 0UTLETSSWI7CHFSHXTUAES
pp applIcanlfor a permit subjects the applicant to a civil penalty of not more than
FI (SeF70K
red dollan($SOO. � .
NEW RESIDFMIAL ELFCTR STORIES TYPE CONSTRUCTION
owner of the property,or my employees with wages u their wk
tlon,will do the work and the structure is not intended or offered for l�
.Busintaand Profeselma Code:The Contractors License Lawpply to an owner of property who builds or improves thereon,and OCC.GROUP R TI5
who doessuch work himself orthrough his men employeet,provided that such
improvements are not intended oroffered forsale.If,however,thebullding or TOTAL: t Sb
improvement V sold within OvyearofcampidiDglMoovner-builderwlllhceve
tqe�Dmenof proving that he did not bund or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE .
LJ FLOOD TINE APN
I,as owner tr the property,am exclusively Business
and
licensed PERMIT ISSUANCE
coo Contraco mnslmdehLaw due not ec.7044,
and Professions Code:
The Coor .impre License law does not apply to an owner of property who ALTER DRAIN&VENT, WATER(EA)
Wilds or Improves thereon,and who contracts for seen projects with a FEE SUMMARY -
,�tfIador exempt
under ane to the Contractors Lkscar Law. BACK RA W PROTECT.DEVICE OUTSIDE FEES
IJ 1 am exempt under Sec B &P C for this re
aeon DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
Owner Date AECEI'f If
WORK MAN COMPENSATION DECLARATION FD(.NRES-PER TRAP SCHOOL TAX Y N
❑I hereby affirm that I have a artl0cate of consent to self-insure,ora RECEIPT N
certificate of Worken'Compeniatioe Insurance ora certified copy thereof(Sec. GAS F.A.SYSTEM-11NCAOUTLETS PARK FEE Y N
3800,lab C.) RECEIPT N
Policy N CAS IA.SYSITMAVER 4(EA)
Com any BUILDING DIVISION FEES
Certified copy 6 hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK PEE
❑CerBfied copy is filed with the city Inspection division.
CERTIFICATE OF O(EMPDON FROM WORKERS' GREASE TRAP - PAID
COMPENSATION INSURANCE SLWER SANRARY STORM EA 200FT Date Recd I#
(1'hlssectlon need net M completed tithe permit a for one hundred dollars
($IW)mless.) WATER]-IEATDi W/VFNf/FLFCTR ENERGY FEE Y_ N
I cerifythat In the performance, w
e,ofthework forwhich this permit Is oed,
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workers'Compensaitan Laws of California.Date PAI D
0 Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOnCETOMnICANT:I,afternakingthb C.Alfimteof Exemption,you
sM1ould become subject to the Workers'Compensation provisionsof the Labor TOTAL:
~ N Code,you=at fort hwith comply with such provisions or this permit shall be '
W j deemed revoked. BUIL TNG FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Il Iherebyaffireetleat thea Lsamvlrudlun lendingagenryfortheperform ELECTRIC FEE
7 Z an ofthe work for which this permit b Issued(Sec.3097,CIv.C) TOTAL:
O O Lenders Name - PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT PEE MECHANICAL FEE
OW ImnlfythalM1 vereadthbappbmtionandstatethattheaboveinformaticn
1 coned.I agree to comply with all cityand county ordinances and state laws PFRMTTLSSUANCE FEES PAID:
>. relatingto building construction,and herebyauthortee representatives ofthb
N city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MFCH.
? (We)agree to save,indemni an d keep hare".the City of Cupertino Date Receipt#
V against llabillties,pdg ,co dexpenseswhtchmaylnanywayamrue AIRHANDLINGUMT(TO10,00)CFM) SUBTOTAL:
againsts Cityln thlsp it.
, �_.,g�L AIR HANDLING UNIT(OVER IB,DBocFM) CONSTRUCTION TAX
sig,al t t adm Date L EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
MA DOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or handle hazardous HEATING UMT(TO 100,000 BTU) Date. Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER I W,"BTU) TOTAL:
E]Y. N No
Will the applicant or Future building occupant use equipment or devices VFI-ITTLAEON IAN(SINGLE REBID) ISSUANCE DATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Mm
a rageent District? BOILER-COMP QHP OR 100,0M BTU)
4 Yes N
have read the haza❑ND materials requirements under Chap[er 6.95 of FK)RER-COMP(OVER lOJ,000 BTU)
the California Health&Safety Code,Sections 2550.$,25533 and 25534. I IIsi x
understand that it the building does not currently have a tenant;that it k my NEW RESIDFNHALMECIi. SQ.FL '1'+AY `' i
Apno
bilityto dify the occupant of the requirements which must be met \V�
ssuan f a Ompancy.a t gent —Fate ISSUED TOTAL: BY: �-e s�✓ a= 'J•
OFFICE COPY