22716 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Bull in AddreBuildin Project Identification PFR.WTNO.
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a ante: s e: A A
CITY OF CUPERTINO-BUILDING DIVISION
l ceder. n Um 1 Lie.No: APPLICATION /PERMIT CC
V' BU[LDINGdECTRICALPLUMBINGMFLHAMCAL CATEGORY CONTROL N
Archil /Engineer. Lic.No:
^�q, QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address, W w' PERMITISSUANCE ❑ ❑ I4z?r O
LICENSED CONTRACTOR'S DECLARATION LIS
l hereby affirm that l am licensed under provisions of Chapter 9(commenc. APPLIANCFSRESIDENTIAL JOB DE M-1 ION
Ing with Stolon 70W)m Division 3 ofthe Business and ProfnedoesCode,and my
license is In full force andPANELS
ansc Cuss LIOc.N
DNUP TO 2DOAMPS P
I` IIL'1-11
Bate Contractor Ml10DOAMIS
ARCHITECTSDECLARAITON OVERIODOAMPS SQ.FT.FLOORAREA S/SQ.FT.
{ppEuuaZ luvde.tand my plan slug be used as public records
E%Ob W Licensed Professional SIGNS ELECTRICAL LED I N
<Q OWNER-BUILDER DECLARATION
Fn Fn SI'ECIALCBtCU1T/MISC IN
s. Z owning ason.&' chat lamexempfromthe
andPrractsionsCdeeLaw fmthe P T R
ZO�N u9 following reason.(Section r0 t to Business and Profess Wee Code:Any tlty it Tpyp,METER OR POLE INST.
countywhich requlrcsa permit loconslruct,ager,improve,demolbF,orrepair
¢K�[�j anystructure priorto its issuance,also requiresthe applicant for such permit to ]OWER DEVICES / /
a n< U file a signed statement that he is licensed pursuant to the provisions of theDkm
�30� C o3o u'.Lice.Lnd hapternsCommenFegwihe lseumlonth�indDivi- SWIMMING POOL ELECTRIC VALUATIONO
a the basis for the alleged exemption. Any violation of Section 701.5 by any
appBanl for a permit subjects the applicant to a civil penalty of vat mare than OUTLETSSWITCHESIIXTURES
w O live hundred dollars($500B. NEW RESIDENTIAL ELECTR FT.
,$ SQ. SNWIS TYPE CONSTRUCTION
❑I,as owner of the property,or he employees with wages r thele sole
�7.¢ compensation,BuldosMwProfesloestrutturcls Contrandedo License
ed for
Law
��D sale(Sec.7014,Business and Pro(essloru Code:The Contractors Llcensc Law
F1is$ don not apply to an owner of property who Wilda or improves therron,and
EE whodosuchworkhImeatforthrough hisown employees,provided thatsrch OCC GROUP RES.UNITS
n
Improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improvement issold within one yearof completion,the owner-bullderwlll have
t rdenofpmving that he did eta Wild or Improve for purpomo(sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed
contractors to construct the project(Sec.7014,Business and ProfessPERMIT ISSUANCEions Code: -5710
The Contracture Limns Law don net apply to an owner of property why ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon,and who contracts for such projects with a FEE SUMMARY
c7a4actor(s)licensed pursuant to the Contractors License Law. BACK FLAW PROTECT.DEVICE
LJ I am exempt under Sec R Na P C for this reasonOUTSIDE FEES
DRAINSFLOOR ROOF,AREA,COND. SANITARY Y_ N
• Owner Data ftECEIIrTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCIiOOL TAX Y_ N_
❑1 hereby affirm that I have a cortllkate of consent to self-Insure,w a RECEIPT N
cortifiateofWmkers Compauaticars Insurance oracartifird ropyths.f(Sec. GAS EA.SYSTEM-1 WCAOUILETS PARI F= Y_ N_
3800,lab Q
RECEIPT#
Policy N
CGAS EA.SYSTI]rf-OVER 4(EA) BUILDING DIVISION PEES
C. an '
ffCeny ified ropy is hereby furnished. GREASE/WOUSTRL WASTE INTERCEPTOR PLANGHECIC FEE
e ified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FTDate Recei t#
(rhlsseallon need not be completed if the permit is forone hundred doll..
(SIO(Borlees.) (NATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N—
I certifythat in the performance of the work forwhich this permit is Issued,
L shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
WorkerCompensation Laws of California.Date PAID
OZ Appllant NEWRESIDFNTIALPLMB. SQ.PT. Daft ReCCI t#
Z O NOTICE TO APPLICANIT:ILaRt,r ma king this Certiiau.f Exemption,you
should Wcome subject to the Workers'Compensation provisions of the Labor TOTAL:
CC N Code,you moat forthwith comply with such provisiom orthb permit shall be BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that mere ls a construction lending agency for the perform ELECTRIC FEE
M Z sect,of the work for which this permit isissued(Sec.3097,Civ.C.) TOTAL: t,0
00
(,.dors Name PLUMBING FEE _ 00
LL Lenders Adaree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
ationand statethatthcabwe information
O
1 Is correct.Ice to compI ithalldtyandrountyoedlnanasandetatelawe PERMIT ISSUANCE FEES PAID:
>. W relatingl ild gronsruction,and hereby authorize represenfnives ofthis '
H Z city to W nth,abovo-me propert for mspt,ction rpoxs. ALTER OR ADDTOMECH. Date Receipt#
e)a to or,
Ind Ify d east
h o/Cupertl AIRHANDLINGUNU(TO10,0DOCFM)
U Dietl Idea,rydg s pan a hi yI a. way SUBTOTAL: .O'0
•gal Id City in oat ag:r o ape B.
AIR HANDLING UNIT(OVER 1Q000 CPM) CONSTRUCTIONTAX
turem Appllcan onhactor D EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISC UR
Will the apptlant or future building occupant so orhandleharardous HEATING UNIT(TO 100,000 BTU) Date ReceI t#
material as defined by the Cupertlre,Municipal Code,Chapter 9.12,and the
Ilealth and Soddy Cade Section 25532(a)7 HEATING UNIT(OVER IOO,DDO BTU) TOTAL:
❑ Yea NN.
Will the applicant or forma building occupant use equipment or devices VFMILATION FAN(SINGLE RESID) ISSL ATE
which emit havrd....ireommurcims.s defined bythe Bay Arca Air rf��
• Quality Management District? BOILER-COMP OHP OR IO(iOID BTU)
Yes No
have rad the hua ous materials requiremente under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 1991
the California Health h Safety Cade,Sections 25505,25533 and 25534.1
unde.t.ndthatifthe WlldivgdoesnotarrentlyhaveatenangtWtitismy NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which roust be mart C*ot CUD""
prior to Issuance of a Certificate of Occopancy.
e
Owner or authorized agent Data TOTAL: ISSUED BY:
OFFICE COPY