22818 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE-BALL POINT PEN ONLY
BuildingProject Identification � —isePERMIT NO.
Building Address: - 2^^ /f n
wn=re ams: - one: G qG ljl( I }V(
�-C 707/q CITY OF CUPERTINO-BUILDING DIVISION 0^��
Contractor's Name: Lic•Nm: APPLICATION /'PERMIT
BMLDING-ELBCTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL#
Architect/Engineer. Lic.Na
-�. QTY . ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: CT Core,*TI
PERMLTISSUANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION - -
IherebyaHremthatlamlicensed under provisions ofChapler 9(commen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
ingwlth Section 7000)of Division 3 ofthe Businea°andProksslonsCode,and my
Li...Cie. force and Lic.# !10 PANELS G am. • - .
R
Data 4O—�_�`j Contractor
ARCHITECT'S DECLARATION 101-1000 AMPS
0 O I understand my planeshall be used as public records. - OVER 1000 AMPS SQ.Fr.FLOOR AREA SM.FT.
b;b�j Lirensed Profesaioral SIGNS ELECTRICAL r (^' r fl
Q& - OWNER-BUILDER DECLARATION SPECIAL CIR61IT/M75C 1
i-, I hereby aNrce that l am exempt from the Contractors License Law for the _
QQ pp following reason.(Section 7031.5,Budness and Professions Code:An or rypee
FN
county which requires a permit to construct,alter,improve,demolish,Any
repair TFMP.METEROft POLE INST. 1J T 14o tl ■
qq� any structure prior to its Issuance,also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the Provisions Of the POWER DEVICES V/ /
3O� Contractor'sL,r—Law(Chapter9(ce—acingwith Sectbn700()of Divl- SWIMMING POOL ELECTRIC'
sion3Ofthe Business and Professions Code)orthat he is exempttherefromand - /�VALUATI
O the basis for the alleged exemption. Any vldatlan of Section 7031.5 by any OUTLETSSWIICHESF[XTURES A
applicant fore perealtsubjectstheappllcanttoacivii penattydm
not orethan ` J
gg five hundred dollars(S50).to NEW RESIDENTIAL ELECTR SQFT. STORIES TYPECONSTRUCITON
�m ❑compensation,a owner of the property,or he employees with wages r there°ole
ls&c. 44will do Business workand the structure The
Coet nnector or offered for
O
data
cpply toa.Owandf property Code:The orimpoves Lirenae Law
does oossucy torn imserofprough who nemporimproovidedreoryand
who doesauchwork hlmselfwthtough his ownemployeee,provided that such ---OCC—GROUP RFS.UNITS -
improvereenh are not Intended proffered for sale.If,however,thebuilding or TOTAL:
improvementismldwlthinoneyearofcomptetion,theowner-bullderwlll have t
�I . th*rden of proving that he did not build or Improve for purpose of sale.), Qry', PLUMBING PERMIT FEE #LDZDNE APN
- u L as owner of the properly,am exclusively contracting with licensed
P contractors to construct the project(Sec.7044,Business and Professions Code: PERMIT ISSUANCE
The Contraetore License Law does not apply to an owner of property who AI.ILR DRAIN Is VENT WATER(Eli)
builds or Impruvee thereon,and who contracts for such Inyiects with a ec FEE SUMMARY
ado 8)licensed pursuantto the CoatraRorb License Law. " BACK FLOW PROTECT.DEVICE
LJ I am exempt under SB &P C for this reawnOUTSIDE FEES
\� Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_ '
RECETT#
WORKMAN COMPENSATION DECLARATION
FIXTURES.PER•IRAIa SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of consent to self-more,Or a RECEIPT N
certificate OlWorkera'COmon persatiInsurer.ora certified copy thereof(Sec.
3800Lab C.) GAS PA.SYSTEM-1 INC.40UTLElS PARK FEE Y N
S _
, n t_ n
'� Policy# C�n. 1('JI I C J ("I( ICkIi�V
Cnya+ GAEA. RE(:®'Tp
BUILVER4(FA) DING DIVISION FE ES
yup
Certified copy is hereby filed
the ed.city GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
edified copy is flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID 1
COMPENSATION INSURANCE SEWER SAMTARY SZORM EA 100FT Date Recei t#
(Thi.section need not be completed lithe permit isfw one hundred dollars
(9100 or less.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I eertifythat In the perforrtunm ofthework forwhlch this pernit isissued,
I shall net employ any person in any manner so as to became subject to the WATER SYSTEM/TREATING
Workers'Compeasation Laws of California.Date PAID -
O Z Applicant NEWRESIDENTIALPLMB. SQ,FT. Date Recei t#
Z Q NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
Ln Code,you=at forthwith comply with such provisions or this permit shall be
Uj > deemed revoked. BUILDING
CL
c . CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmtbet there is a construction lending agency forthe perform TOTAL: ELECTRIC FEE
L) Z once of the work for which this permit is Issued(Sce.3097,Civ,C.)
C1 O Lenders Name PLUMBINGFEE
F lenders Address QTY. MECHANICAL PERMIT FEE
O W . Irectifythailhavemadthisnpplkatlonand°tatethattheabmelnformation MECHANICAL FEE
a Iscorrect.I agree to comply with all diyand county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} N relating to building conatructlon,and hereby authorize representatives of this cityto entero on the above-mentioned roc fou inspection ses. ALTERORADDTOMECH.
~ ? (We)agree to save,Indemnify an d keep h rMeea the City or Cupertino Date Receipt#
O against liabilities,judgments,costs and expenses which may in any way amve AIR HANDLING UNIT(TO I(IM0 CFM) SUBTOTAL:
agamstsald In consequence of the granting of this permit.
1 AIR HANDLING UNIT(OVER I0,oa0 CFM) CONSTRUCTION TAX
4J4SI I ural a _ Date IXHAf1ST HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
111 a licant or future building ores ant store Or handle hazardous HEATING UNIT(TO 100,000 BTU)
PP B P Date Recei t#
materlal as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Health and Safety.Code�5ect1on 25532(a)7, HEATING UNIT(OVER 100,000 BTU L; "
F-1YouL_I No
Will the applicant or futurebuilding occupant use equipmentordevices VENTILATION FAN(SINGLE RESID) ISSUANCE D T
which emit hazardous air contaminants as defined by the Bay Area Are 1� �
Quality Management District? BOILER-COMP DHP OR]00,0(1)BTU
Ym ❑No
4hiveread the
hazardou°materials requirements underChapter6.95of BOILER-COMP(OVER 100,000 BN) s �
the Califomis Health&Safety Code,Sections 25505,25533 and 25534.I 04 IAUDR�IB19
understand that if the building does net earrently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.FI. City,
responsibility to notify the Occupant of the requirements which must be met
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent . . Date ISSUED BY:��s/ -
TOTAL:
OFFICE COPY