22839APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —USE BALL POINT PEN ONLY
Building Project IdentificationP1JlMTNO.
Building Address:
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.cs �`
- 22839
amrllll
N��AE
�ractin,. Na me: Lic. No:
CITY OF CUPERTIN6BUILDINGDIVISION
APPLICATION / PERMIT
A
BUILDINGELECTRICALnUMBING-MECFIANICAL
CATEGORY
C
ArcM1ited/Engineer: He, No:
QTY ELECTRICPERMIT FEE
BUILDING PERMIT INFO
IT
Address:
PERh9TIS5UANCE
1:1{IM
LC
LICENSED CONTRACTOR'S OCCLARATION
I herebya(firmtMt l ace licensed under prevail .... f Chapter9(conunene-
ingwlth Section 7DOO)of hAslon3 ofthe Biulnessand PmfeadoesCods, and m
license is in full form and affect.
APPLIANCESRESIDENTIAL
BDLSCRIPHON
PANES
License Clam LIc.X
Data Cormad er
J— UP TO 20DAbM
211-1000 AMPS
ARCHITECTS DECLARATION
Iunderetand my plans ehalM used as public records
Professional Pesslonal
OVER 1000 AMPS w., �
SQ.
aasAREA
[Ry,,,,FLOOR
$/eJ,j. FT.
SIGNSELECTRICAL -�� –�. �uZo
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt (romthe Contractors License Law for the
SPECULCIRCUIT/MISC
TEMP. METEROR POLE ]NST.
POWER DEVICES OA E
following reason. (Section 7071.5, Business and Professions Code: Any city or
rountywhlch requires a permittommtmd, alter Improve, de=lish,ormpalr
anystmmmpdortoiUW ance,atsorequlmtheappbmnt(orsuchperMtto
file a signed statement that he is licensed pursuant to the procrisiau of the
Contractor's License Law (Chapter 9(mrmnencing with Section 7000) of INA.
slon3ofthe Businessand Profemiom Coae).,thathnlse emptthemfmmand
the bash for the alleged exemption. Any violation of Section 7071.5 by any
applicant fore permit subjects the applicant to a civil penalty of not nnrethan
SWIMMING POOL ELECTRIC
O OUTLETfrSWITCHESFIXTURES
VALUATION
'`
3z (.00 ,_
NEW RESIDENTIAL ELECTR --SQ'Fr'
five hundred ..Ilan (55(0).
❑I, as owner of the properly, or my employees with wages as their sole
STORIES
TYPE CONSTRUCTION
compe... tlon,wBl dolts work, and thestmdure is not intended or offered for
-
sade (Sec. 70K Business and Pm ireadom Code: The Contractors License Law
does nn apply to an owner of property who builds or improves thereon, and
who does such work himself orthrough his own employees, provided that such
R[S. UNITS
ImIprovements are not Intended oro(fered for ule. If, however thebullding or
loop meet issokl within oneyear°(completion, the owner-builderwlll have
CXW
TOT
t r Iden of proving that he did not build or improve for purpose of sale.).
owner of the Property, am exclusively contracting with licensed
structure to mmtmud the project (Sec 7044, Business and Prof.iou Code:
QTy. PLUMBINGPERMIT FEE
pEEM17I55UANCE
PIAODTANE
APN
e Contractor's License Law does not apply to an owner M property who
W Ilds or 1 proves thereon, and who centrads for such pRojeda with a
mpgado E enscipunuantt he C.ntndor'BLlcense Law.
LJ I a accept under Sec. B r P C for this reawn
ALTER -DRAIN k VENT- WATER BlA)
BACK FLAW PROTECT. DEVICE
FEE SUMMARY
OUTSIDE FEES
DRAINSFLOOR ROOF, AREA, COND.
SANITARY Y_ N_
RECEIPT N
O,me
C HATION DEC" KION
❑I hereby aif that I e • redNute of consent to uI-inwre, or
cediflmte.(Workemi Cam Hon Insurance or a reddled ropy thereof(Sec.
3500, Lab C3
FD(LVRHS PER TRAP
SCHOOL TAX Y N
RECEIPT N
CAS F.A.SYSTEM-1 INCA
PARK FEE Y_ N_ '
Y
RECEIPT p
GAS EA. SYSTEM -OVER d (EA)
Go
Com any
BUILDING DIVISION FEES
Certified copy le herebyfurnished.
Certified cepyVfiled with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(I) need red M completed I tM pemdt V (or orae hundred dollars
CREASE/INDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
� a60
PAID
GREASE TRAP
SEWER.SANITARY-STORM EA 2WFT
Date RetY'1 t# saft
m Icelon
($100)., lemJ
I mrtlfy that In the performance of the work forwhich this permit is issued,
I shall not employ any person in any manner so as to became subject to the
Workers Compematlon Laws of Cali(ornla. Date
WATER HEATEi W/VENT/F3.ECTR
ENERGYFEE Y
— '
PAI p
WATER SYSTEM/TREATING
Applicant
NOTICE co APPLICANT: If,a after rs Co this
sationipro of Exemption, you
Code,shoulbroom forth to the Workers' such provisionsorthioruofthe Labor
Code you must forthwith comply with such provielav orlhh permit shall be
deemed revoked.
ate Recel t#
NEW RESIDENTIAL PLMB.SQ.FT.
TOTAL:
CONSTRUCTION LENDING AGENCY
]hereby alfirmtMttherc lsamr:stmdlon lending agency (or the perform-
ance of the work for which this permit Ls Issued (Sec. 3097, Civ. C.)
S IC F
TOTAL. '
EE RI
Lenders Name
LcndcreAddress
Iredifythatl MvereadthlsappBcationand state that the above Information
-
QTY. MECHANICAL PERMIT FEE
PLUM H
MECH L '-E
FEES D:
iscerred. l allocatecomply with all city and county ordinances and slate laws
PERMIT ISSUANCE
relating to building construction, and hereby authorize representatives ofthis
city to enter upon the above-mentioned property for inspection purposes.
(We) a c 1. ave, Indemnily and keep harMen the City of Cupertino
ALTERORADDTOMECH.
Date Receipt#
UBTOTAL:
agaimt 'daa,jydgments, coarsen expenxs which may In anyway accrue
at a fly In mnsryue cacti grantintieg.(this pe C
AIR HANDLING UNIT (T010pWCFM)
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTI TAX
Ig u of App Ica trail Date
E(HAUSTHOOD(W/DUCT)
CONSTRUCTIO TAX PAID:
N RDOUS TE RIALS DISCLOSURE
HEATING UNIT (TO 100,000 BTU)
Wllitheappit"iI or future ding occupant store or handle hazardous
matelot as defined bytM Cupe no Municipal CWc,Chapter 9.12, and the
Fleakh and Sifdy CWa Section 25532(a)7
❑ Yes No
D_ aD RCC t#
TOT
HEATING UNIT (OVER 10BOW BTU)
VENULATION FAN(SINGLE SID)
ISSUANCE DATE
Will the applicant or Lure building occupant use equipment ordevicei
which emit hazardous air contaminants as defl°ed by the Bay Area Air
BOILER-COMP(310 OR I00,000 BTU)
Qua lily Management District?
Yes ❑
4
/
BOILER-COMP(OVEt 100,000BN)
have read the bass N ossNoa matedah requirements underChapter 6.95 of
the California Health k SafetyCode, Sections 25505,25533 and 25534.]
understand that lithe building does not currently have a tenant, that it is my
'CTI r '�OfSF
NEW RESIDENTIAL MECH. SQ.IT.
mponsibllity to notify the occupant of the requirements which must be ,net
V
prior m Issuance of a Cedlflcate of 0cmpancy.
a
ISSULD BY :
Owner or authodud agent pate
TOTAL:
OFFICE COPY