22827 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification
Address: PERMIT NO.
Building
zzSSaL.LEVUE 22827
° ams hone: A
CITY OF CUPERTINO-BUILDING DIVISION
c°" n N G APPLICATION /PERMIT
BUILDINGELECTRICAL UMBING HAMCAL CATEGORY CONTROL It
Arrhltect/Engineer. Lie.N.:
QTY ELEC PER FEE BUILDING PERMIT INFO
Address:
�^�
5L MECH
LICENSED CONTRACTOR'S DECLARAIION PFRMITISSUAN
I Mj licensed derpmvislo apter9nc APPLIA RESIDE
IngwlthScton7OW)ofDiWtlan3oftheBu11nessandProf.aonaCode,andmy JOBDESCRIP11UN
license Is ie coil and t.#M P was _v)4,s 6 -_ \
licensees iass�_Llep _ IIT 1F\'-"ls ` R LlV1/1
Date Contractor
ARCHITECI75 DECLARATION I-1000 AMPS
µQS ON QO
fund tan p na°hall be used as public record°. OVER I ODO AMPS SQ.FT.FLOOR tjRaFA 5/SQ.Ff.
E�(3 Licensed Professional SIGNS ELECTRICAL ✓� ' / ' 171-6�
OWNER-BUILDER DECLARATION SPE(:)AL CIRCUIT/MISC — 1p
owing rasormthatlam31.5,B from the Contractor's Code:Any
fort he `
OZtF rs countywreason.(Sectionrmi1.5,Business truntand Professions Code:Any dty or
p4 [3�i
county requires pertNe to mnstrucl,alter,impmve,demoWllorrepalr TEMP.MUM OR POLE INST.
any Structure prior to it.issuance,also requires the applicant for such permit to ppyygR DEVICES
Yd file a Signed ehtement that M b licensed pursuant to the proWlous o! the
3wt, Contuntor'sLicense Law(Chapter 9(commencing with Section 7000).1Divi- SWBr1MING POOL ELECTRIC
SOS sins 3ofthe Business and Profeaeloru Cole)orthat he a exempt ISfromand VALUATION
G£ the basis for the alleged exemption. Any violation of Section 7071.5 by
OUTLETSSWITCHE&.FIXTURES �~ ^S Q�°'1` �tfs.e•
❑ appBcant for a permit Subjects the applicant to a civil penalty of not morethan e/4 ` W
five hundred dollars($500).
�n nI,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. SCOItIES TYPE CONSTRUCTION
,5 < compensation,will do the work,and the Structure is not Intended or offered for
�11 ❑ elle ISM 7044,Business and Pnefe sinus C°ds:The Contractors License Law
p�$ does not apply to an owner of property who Wilde or Improves theremy and
who does suchw.,k himself orthrough his own employees,provided that well RES.UNITS
improvements are not Intended oroffered for sale.If,however,thebuclding or T
Improvement issold within.neyearofcompletlogtheowner-buliderwillhave
tFkrkiurden of proving that he did not build or Improve for purpose ofsaleJ, QTy. PLUMBING PERMIT FEE
LJ L as owner.f the property,am exclusively contracting with licensed APN
contractors to coostroct the project(Sec.7044,Business and professlors Code: PERMIT ISSUANCE
The Contractors License Law dues not apply to an owner of property who
bulkts or improves thereon, and who contracts for Such project ALTER-DRAIN VFM-
with a WATER(EA)
cgB(Pemr(eI licensed pursuant to the Contrador'S Lt...Law. FEE SUMMARY
LSI am exempt under Sec. B&P C for this reason BACK PLOW PROTECT.DEVICE OUT51 OF FEV q
Owner She DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
WORKMAN COMPENSATION DECLARATION RECEPr p
❑I hereby affirm that 1 have a certificate of consent to self-maure,or a FD(TURRES-PER TRAP. SC TOOL TAX Y N
3800,
cenifimte cf Workers'Compematlonlmurance ora certified mpythemof(Sec. 1 RECEIPT St
Isis C.) GASEA.SYSTEM-IINC.4OUTLElS PARK PER Y N
Policy p RECEIPT p
Com any - GAS FA.SYSTEM.OVER 4 MAI BUILDING DIVISION FEES
ed copy Is hereby th the city
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEL 0J
Certl(iad copy B filed with the city Inspection division.
CERTIFICATE OF E)EMPTION FROM WORKERS' GREASE TRAP PAI
QIZa
COMPENSATIDN INSURANCE
(Thlesectl.nneed not becempleted BlMpermit isfor.nehundred dollars SEWER-SANITARY-STORM EA.200F7. Da[ cel t#
(51Imaifyth WATER HFATFRW/VENT/ELECTR EN F N
I certify that o the performance any
manner So as to b tha penult a issued,
I shall not employ any person In any manner eo ce to become subject to the
Workera Compensation Laws of California.Date WATER SYSTEM/TREATING PA
Z Z Applicant Q \�
Z 0 NODCETO APPLICANT:If,after making this Certificate of Exemption;you NEW RESIDENTIAL PLMB. SQkT. Date Re
Should become subject to the Workers Compersatl.n provisions of the Labor TOTAL:
N Code,you must forthwith comply with Such provisions or this permit shall be
W > deemed revoked. BU DING E
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafflrenthat there IS a construction lending agency for the perform- FE40
Z ance ofthe work for which this permit is Nsuad(Sec.3097,Civ.C.) ELECTRIC E 4,
V O lender.Name PLUMBING FEE
IL h Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I certilythatl have readthis application and smtethatthe above Information
1 rammct.I agree to comply with all city and county ordinances and sate laws PERM77155UANCE FEES PAID.
>. N relating to building construction,and hereby authorira representatives of this
I'_ Z city to enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
(We)agree to Save,indemnify an If keep harmless the City of Cu portion - Date Recei t#
againstI bcllties,Y g=,mss and experniswhich may In anyway accrue AIRHANDUNG UNIT(TO 10,ODOCFM) SUBTOTAL:
ag.lnet CllyI songs nue of he sting this Fermis.
y. AIRHANDLING UNIT(OVERIg000CFM) CONSTRUCTION TAX
growl pp cant p a rpt EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HA7A I MATERIALS i CLOSURE a /y.
Wil h applicantwfu cbuilding occupant stare orhandlehazardo. HEATING UNIT(TO I0LW0 BTU) Date Recei f#
materi defined by tM Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTI!) •1.0.1•
r-1YeaNo
Will the applicant orfuwre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haearlom air contaminants as defined by the Bay Area Air
ality Management District? BOILER-COMP 0HPOR 100,000 BTU)
Yee No
PAID
have read the laza[ nus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Callfornla Health&Safety Code,Sections 25505,75533 and 25534.1 ��� 14 ����
understand that if the building does not currently have a tenant,that It 6 m NEWRESIDFNUALMECH. �.Fr.
naporsibillty to notify the occupant of the requirements which must be met C
prior to Issuance of a Certificate of Occup.nry. CITY UF CUPEH I
Owner or authorised agent Date —�. ISSUFD6 `��
TO
OFFICE COPY