22103 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BufldIng Pru ed identification PERMIT NO.
B°°ding Address: 22103
A
weer. one.me _<3-9S CITY OF CUPERTINO-BUILDING DIVISION
Contract •Nam: Lic.N. APPLICATION / PERMIT
s2�7� BUILDING-ELECnUCAUPLUMBING-MWIIAMCAL CATEGORY CONTROL a
Architect/Englnar. - Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address y`ss / PERMITISSUANCE ❑ ❑ ElLICENSEDCONTRACTOR'SD LARATION
I hereby.
I am Lemsed under provisions of Chapter9(commene- APPLIANCESRESIDENTIAL JOB DLSCRTPTION
Ingwlth Srdkm7000)ofDtvlslon3 ofthe Buslnessand ProfessionsCode,and my , I
Been le In fu0 farce and d(ect. PANELS xI /!1"1
License CkssLlr.M ��.2 �7S
Date_
ARCHITECPS DECLARATION 201-IODDAMPS
oto QCC l understand my plans shag be used as public rawnds OVER 1000 AMPS /S.FT.
o U Licensed Professional SIGNSELECTRICAL /p� P
OWNER-BUILDER DECLARATION SPECIAL ORCUIT/MISC COID a ssR
F, a Iherebyaflmothat l am exempt from the Contretlor's License law forthe
Q qqqq following rtawn.Okctlon 7mlS,BusinessaM Profession Code:An tl r
OZry countywhich requires a permit tuconstruct,alter,Improve,demolbh,or repair TEMP.METPR OR POLE INST. '� Ly
qqq''� 3< anystmcture prlorto its Wuance,aborequlreathe applicant forsuch permit to
V file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES '
XOwl Cormictorb License Law(Chapter 9(samk VALUATION
tamecing with Section 7000)of Divi- SWIMMINGPOOLELECTRIC 05 sion 3ofthe Business and Professions Code)or that he exempt therefrom and
O the task for the alleged exemption. Any violation of SMlon 70)15 by any OUILETSSWITCHESFIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
$
five hundred owner of hepr. NEW RESIDENTIAL ELECTR SQ.FE STORIES TYPE CONSTRUCT ION
�n ❑T,as owner of the the work,
a or he employees with wages as there sole
compensation,K Sodium,
,•work foolonsC dere b not Intended or coffered for
O sdon ale(Sec.70K to aowne df property
who builTheds
or terpctofs License law
�$
who does
apply roan imserdprough who .emoy..,provided
that
cuch OCC.GROUP RES.UNITS
whodoessuch work intended
throughhisowns.If,ho e,however,
thatsuch
improvemcnb arenotintended car ofca far sale.If,howevcythebuiklkgve TOTAL:
improvement baold within oneyeamfcampletlon,the owner-bullderwRl hese
tFW_�Iurdeo of proving that he did not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively mntrading with licensed
contractors to asstruct the project(Sec.7046,Business and Professore Code: PERMIT ISSUANCE
The Contradork License law does not apply to an owner of property who pI,T}]t-DRAIN&VENT-WATER
builds or Improves thereon,and who contracts for such p(ojew with a FEE SUMMARY
MM
c9at[actor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for this reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT If
WORKMAN COMPENSATION DECLARATION Fp(TURES.PER TRAP SCHOOLTAX Y_ N
❑1 hereby a((4m that 1 have a certiftute of consent to aelf•Inare,o a RFCEPT a
certificate o(Workere'ComperwHonlruurence or a certified copy theta!(Sec.
3?` C.) CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N_
PdIgM NJ �_ U'JDO PT a
GAS EA.SYSTEM.OVER4(EA) DING DIV
Cam any BUILDING DIVISION Fr.ES
[PCertlfled copy Is hereby fumished. GREASE/INDUSTRL WASTE IFITERCEPTOR PLANCHECK FEE
ICT Certified copy b filed with the city inspection division.
V+ CERTIFICATE OF MEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SAM.I.ARY.SMRM EA XIOF•f• Date Remi t#
(Thisaeneed not be completed lithe,permit btor one hundred dollars
(8100)arlessct.)0 WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
Icertifythat lathe pedormance of thework forwNch this permit is issued,
I shall not employ any person In any manner so as to beams subject to the WATER SYSTEM/TREATING
Workers'Compensation Lawn of California.Date PAID
licant
Z Q NOTICE TO APPLICANT-.ILafter ma king this Certiicateof Exemption,you NEW RESIDENTIAL PCMB. SQ.FT. Date RCmI t#
should become subject to the Warkers'Compamation provisions of the Labor TOTAL:
W Code,you=at forthwith comply with such provisions or this permit shall b,, UILD
LU 9 deemed revoked.
a G ING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there b a construction lendingagency for the perform TOTAL: ELECTRIC FEE
0 anceof the work for which this permit Jai usued(See 30W,Civ.C.)
Lender'.Name PLUMBING FEE
LL H Lender'•Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfy that l have read thkappliotlonand statethattheahove Information
4 kcomed.I agreeto comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
>. relatingtobuildlegcomwctlon,and herebyauthorlaorepmentativeso(thio
}_N city to enter upon the abovo-mentloned Property for inspection Purposes. ALTFRORADDTOMECH.
? (We)•gra to save,Indemnify an d keep harmless the City of Cupertino Date ReCel t#
V against liabilities,judgments,was and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL'
xg�t d City�s. t ng of this permit
11 � AIR HANDLING UNIT(OVER IO,OJDCFMI CONSTRUCTION TAX
5_ ST roof AppRmm/Contractor ( DaC�te -`/ E)(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or town,building occupant store or handle hazardous HEATING UNIT CTO 100,000 BTU) Date Receipt material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety Cod Section 25532(a)I HFATING UNIT(OVER 100,000 BTU) TOTA
E-1Yes No
Wllltheappllcantor fu turn building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$U TE
which eMt havrdow air rontamlNma as deEmd by/he Bay Arca AU
Quality Management District? BOILER-COMP OHP OR 100,0(,BTU) ��
Yee ❑No A� C 199
have read the hazarclous matedais requiewrics under Chapter 6.95 of BOTLER-COMP(OVEt 100,000 BN) Ig y
the Califcrnla Health&Safety Code,Section 25505,75533 and 25534.I
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.F7 1
responsibility to notify the occupant of the requirementsm
which must be et
Prior to Issuance of a Certl at fOccopancy. 's-- _
er o authorlud agent Date ISSUED BY: '
TOTAL:
OFFICE COPY �