22537 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMIT NO.
Be ild ing Address:
6a3 �' :�� 22537
nere came: A A A
Cq(q q6(-77't:I - CITY OF CUPERTINO-BUILDING DIVISION
\��a ::'a cameI� � LIc.No APPLICATION / PERMIT Q
ti V•-a..) 1 • (3 BTXLDINC-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL a
••Archited/Engineer. Lk.No: '
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFOPLUMB hff�ti
-
Address: PERMITISSUANCE -(�� �f�Nl ❑ ❑
LICENSEDCONTRACTOR'S
under rDECLARATION yam•
I Mrebcticu,mthat l iv Rcen3ofthe uMnemand Provisions fCssims ode,an enc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingweh Sedbn7000)ot Division3o(the Businessandl'rofessionsCode,and my O �
Ilcense-CLess rce Lic,N PANELS I(('jkl-C.-� 7t/✓Lfty'notIV�'
ate$-/j-91 Contractor gey f T
ARCHITECPS DECLARATION 201-1000 AMPS
pkp�vv rezC I understand my plans shall be used aspublicrecords. OVER1000AMPS SFr.F} orf 1 ^ r-S/SQ.
Fr.
ZU Licensed Professional SIGNS ELECTRICAL !/',IIYIJ�L��'\',.SG.`ty`U(1" w t' 'V
OWNER-BUILDER DECLARATION / O v-+—/-� `
2e. ]hereby alRrmlhallam exemptfromthe Contractor's License law firths
SPECALCIRCUIT MI92
oo following reason.(Section 7011.5,Business and Professions Code:Any city or
OZt"'t9- county which requlresa permit tocommuct,alter,improve,dennlbh,orrepalr TEMP.METER ORPOLE]NST.
any structure primrto ltabsetance,alsorequlreatheapplicanl for such permit to POWER DEVICES
p�ry 5 file a signed statement that he is licensed pursuant to the provisiom of the
03"� Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC UA'llpN
sion3 ofthe Business and ProfeasionsCode)orthat he is exemptthercVAL
femand AL U
$• the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCI-IFSFIXTURES
applicant fora permit subjectathe applicant to a civil penalty M not more fluor
c. a,Ox, five hundred dollars($500). NEW RESIDENTIAL ELECTR
n I,as owner of the property,or my employees with wages as their sob SQ'Ff. 5T0 ES TYPL CONSTRUCTION
�Z< compensation,will do the work and the structure is not Intended or offered for -
sale(Sec.7044,Business and Professions Code:The Contractors License Law
sg does not apply to an owner of property who Wilds or improves thereon,and OCC.CRO RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not intended orotferedfor sale.If,however,thebuilding or TOTAL: -
improvement issold within one yearofcompletlon,the owner-buthierwill have -
t man of proving that he did nW
ot ild or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD%ANE APN
"I,as owner of the property,am exclusively contracting with licensed
centractmrs to construct the project(Sec.7D44,Rusiness and Professions Code: PERMIT ISSUANCE
The Contactors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WA'IF�(F � B f 1
Wadi or improves thereon,and who contracts.for such pmjects with . u �- • , FEE SUMMARY
tractor(s)licensed punuant to the Contradors License Law.
cIi I am exempt under Sec B& P C for this reason IX
cBAFLOW PROTECT DEVICE .x / •- I•TZI It_.• Ownercanes Data DRAINS FLOOR,ROOF AREA,COND:�
l lC'�� jRECEfI'fp
WORKMAN COMPENSATION DECLARATION FIX.IlIRFS PER
TRA]' ipOL TAX N
❑I hereby affirm that I have a certificate of consent to self-Insure,or a -i I
urtlfiate ofWorkert Compenaatlonlvu oracertifkd copythereof(sec. RECEIPI'N
3800,Lab C.) GAS EA.)$Ysl'EHd. C. FEE---! N_
. __ RECEIIPT p
Com M GASFA.SYSTEM-OVER4(EA)
Com any BUILDING DIVISION FEES
Certified copy Is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. DatC RCOCI I#
(This section need not be completed if the permit Is for one hundred dollars
($100>orlass.> WATERHEATFR w/vENT/FL@CTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit b Issued,
1 shall not employ any person in any manner so an to become subject to theWATER SYSTEM/.TREATING
Workers'Compensation laws of California.Date PAID
G Z Applicant NEWRESIDENTALPLMB. SQ.FE Date Recei t#
Z. NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
fshould become sub} to the Workers'Compersation provisions ofthe Labor TOTAL:
Code,you must forthwith comply with such pervisions orthb permit shall be p
W'j deemed revoked. - BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
r 3 0
a'� Ihercbya(Brm that there Is a construction lending agency for the perforce, ELECTRICFEE
7 Z ante of the work for which this permit Is Issued(See.3097,Cm.C.) TOTAL: a
Q0 lenders Name PLUMBING FEE
F' 1.edcr's Address QTY. MECHANICAL PERWT. - FEE
LL MECHANICAL FEE
O W lmdt.Iagretocomply sth allcitynanddc date that theordina cess and
eation
aws
a bcoengto agree to comply with a0 cityandaunty bee repnoesand senoftha PERMIT ISSUANCE F 'S I
N relxtoentWilding mmove-ern,and ionedpoprtyorlcrepresentmlvess.this
city We agree
ee to ave,he indemnify an
property for the Cit purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,indemnity an d keep harmless the of Cupertino Date Receipt#
V as llabilltdgments,cosvaand ex seswhlch may In.anywayamue AIR HANDLING UMT(T010,000 CFM) SUBTOTAL:
agaimtsaidC Con fthea otogofthlspimit.
AIR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTION TAX
Z5! Data / EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
He❑alt hand Safety Code,Section 25532(a)? I[EATING UNIT(OVER 100,000 BTU) TOTAL: .p
Will the applicant or❑future building occupant use equipment or devices V ENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air eons minaots as deo ned by the Bay Area Air g
Y.' Quality Management Dentrict7 BOILER-COMP t00,IXD BTU) r
No
4haveread the h 2usmaterialsrequirementsunderChapter6.95of BORER-COMP(OVER 100,000 BTU) T
the California Health&Safety Code,Sections 25505,25533 and 25534.1Iy RESIDENTIAL MECH. ::Q.I•T t� Ys •�C!
understand that it the building does not currently have a tenant,that it is my
responsibility to notify the occupant of the requirements which at be and gaa�"
prior to issuance of a Certificate of Occopancy. �o
Owner or authorized agent Data 1SSUED��BYBaa Yf141�j[I(�
TOTAL: ����
OFFICE COPY