22202 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
- 22202
D 3 PNS v/��� v
i
n[;r9•alM: one:
W GG Q F W CITY OP CUPERTINO-BUILDING DIVISION
C traetoe Nam: (/� Lm APPLICATION / PERMIT
�L "'� BUILDING-ELECTRICAL PLIIMBINGMECIIAMCAL CAT- BY CONTROL p
Archltect/aBlneer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: III uhi�l PLUMB MULH
PERNITISSUANCE O ❑ ❑
LICENSED that I a CONTRACTOR'S DECLARATION
withSe1 hereby on7OthatlamBcensedunderprovisionsm Chapterodmwd nc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
It...I Sect ion force
of Div ect. (the Buknessand Pro(eeslonsCode,andm
license Is Ins form and e.a PANELS 1L
Llmne[Clam Llc.p '
Date C.ntredor UP TO 2DO AMPS
ARCHITECTS DECLARATION 201-1000 AMPS _
1
Ob I understand my plans shall be used as public records. OVER 1000 AMPS g/EQ.FT.
FL
k Llrensed Professional SIGNSELECTRICAL
dddd� OWNER-BUILDER DECLARATION MA17
1`n SPECIAL CIRCUIT/MISC 'V,
7L., a IhercbyalOmn that[ant exemptfrom the Cantractorb License Lwlorthe
11
O following reason.(Section 7071.5,Business and Professions Code:Any city or
P F' county which mrylma permit tomnstmet,alter,improve,demolish,orropair TEMP.METER OR POLE INST.
anystmcture Inform its Issuance,also requlreathe applicant for uch permit to POWER DEVICES assists, '�a�rY
g file a signed statement that he Is licensed pursuant to the prooblora of the
3rI. Contranae.Licerae Law(Chapter 9(commencing with Section 7003)of Divi- SWIMMINGPOOLELECFRIC VALUATION
O"J slon3 of the Business and Professions Code)or that he Is exempt therefromand IT� �
the basis for the alleged exemption. Any violation of Section 70315 by any J
�dkuj sppBcant fora permit subjects theapplicant toss civil penalty of not more than OUTLE]'SSWITCHFSPI(TURES
6 R five hundred doll..($500). NEW RESIDENTIAL ELECTRf
GG55 n are owner of the properly,or my employees with wages as their sets —SQ'Fr' STORIES TYPE CONSTRUCTION
compensation,wllldothe work and thestmcture 6 not intended or offered for
0 sale(Sec.7044,Business and Professloru Code:TM Contractors License Law
does not apply to an owner of property who builds or improves thereon,and OCC GROIJIa RFS.UNITS
who done such work himself or through his own employees,provided that such
improvements are not Intended proffered for sale,14 however thebullding m TOTAL:
impro,en M6wldwRhlnomyearofcomple Wb theowner-buadermllhave
URj;urden o(provingthat Mdid not build or Improve for purpose of utsJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L�
4..
owner of the property,am exclualvely contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Cade:
The Contractors License law does not apply to an owner of property who ALTER-DRAIN&VFN]'-WATER(EA)
builds or improves thereon,and who contracts for ouch pkppcis with a
cgW.cros(Q licensed pu....t to the Contracts(.Lice.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B &P C for this reawn
. OwnerDate DRAINS FLOOR,ROOF,AIRI!A,COND. SANITARY Y N—
RECEIPT p
KARATION
WORMAN COMPENSATION DECLARATION
FI%1VIffS E'ER TRAP SCI{OOL TA% Y N
C31 hereby affirm that I have a rertlBca a of consent to sel4wm
in ,ora RECEIPT
ceAifimteofWorkers'CompeutiontmaranmwaredifL-deopythereaf(Sm. GAS EA:SYSTFM-1 WC.40IIILE[S PARK FEE Y N
Pod Icy 3800,Lb Cd
GAS F.A.SYSTEM-OVER 4(EA) RECEQa1'
C.m.. p
Cnm any H UILDINC D IVIS ION FE ES
erflHed copy Is herebytumts city city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy Is Tiled with the ciinspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE
(Thisuctlonneed nabecompleted lfthepernat Is for one hundred dollars SEWER-SANITARY-STORM EA.200FC. Date Recel t#
(f100)mfy th WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I cont that o the performance n the work an a to b this permit ubj Isissued,the
I shall not employ any person In any manner at u to become subject to the WATER SYSTEM/TREATING
Worken'Compenutlon Love o(GllfomIs.Date PAID
-
Z Z Applicant NEV✓RESIDENTIAL PLMB._�FI'. Date Recel t#
Z O NOTICE TO APPLICANT:74 after making this Certificate of Exemption,you
Fshould becomesubject to the Workers'Compeivatlon provisions of the Labor TOTAL:
a. W Code,you at forthwith comply with such provisions or this p[rmi[ahall be Casal
WI j deemed revoked. '
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a corutrudlon lending agency for the perform ELECTRIC FEE
M Z ance of the work(.'which this permit k Issued(Sec.3097,CIv,C.) TOTAL: '
U O Lender's NA
PLUMBING FEE
IL Lender'.Add.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEB
OW Irani that lluvercad IsappLLcatbnaM katethat theabovelnfarma0on
1 corlp .I'gream comp with alldtyand muntyordinanresand state laws PLRMRISSIIANCE FEES PAID:
} (L 'statin t buildingconst dlon,andherebyauthodaerepresenlallvesofthIs
Z city t. nt 'upon the toned property for Inspection purpmn. ALTER OR ADD TO MECH. DRIC Reeci t#
— (W)a e to uv e- I and keep harmiess the Cltyof Cupedlno P
aga It. Ntles,pd e,coke net expenses which may In anywayamue AIR HANDLING[WIT(TO 10,000 CFM) SUBTOTAL'
agai tea CI i o the granting of thio permit.
AIR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
'ighaW Appllcant ontra m Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
W It appBunt orfuture building occupant store or handle haeardom HEATING UMT(TO 100,000 BTU) Date RCCCI t#
mate iala defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Ilea)ha Safety Code Scrfon25532(a)2 HEATING UNIT(OVER IDQ000 BTU) .yBLT?OTAL: t
Y nNo E�
I .applicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ass n,]$$�pNp.t7.(��'1'E
which emit hamrdous air contaminants as defined by the Bay Area Air MAY' (y VV �a�,h�
Quality Management District? BOILER-COMP QHP OR 100,000 BTU) �.
4 Yea No
have read the haza pus materfaIs requiremenbunderChapter 6.95 of BOMER-COMP(OVER 100,000 BTU) �fv arts/1a,
the California Health&Safety Code,Sections 25505,25533 and 25534. 1 RILL C'.!
understand that if the building does not mrrently haveatenan4 that ltIsmy NEW RESIDENTIAL MECH. SQJT.
responsibility to notify the occupant of the requirements which at be met
prior to Lssua sere of a Certificate of Occupancy.
Owner or authorlud agent Data ISSUED OY:�a`^� „
TOTAL:
OFFICE COPY