22142 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Prated Identification PERMITNO.
Building Addreae 22142 .
wner ,a--ra,e:, , one: - p
- / CITY OF CUPERTINO-BUILDING DIVISION
Co�aj;:Nante:' Lie.No: APPLICATION /PERMIT J TJ
Y�••ij� `[U BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
p Architect/Engineer. ILII.No: ,
`+ .I.BUILDING PERMIT'INFO
I'ELECTRICPERMIT FEEij
Address: PERMIT ISSUANCE C CA7 '❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
IherebyaffirmthatlamBcerseciunderprovWonso!Chapter 9(rommenc .APPLIANCESRESDEN17AL1 _ P jtaliDESCRIIPT[ON
ingwith Secdon7000)of DivWon3 ofthe Buslnessand ProfessionsCode,and my
license is In full force and died. - - PANELS
License Claes Lie.N
Date Contractor r - UPT0200AWS -
ARCHITECI•S DECLARATION 201-10W AMPS
otO Zp I understand my plans shat be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.Fr.
Fi O Licensed Professionals, SIGNS ELECTRICAL -
6g OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
7
F/F..H, Iherebyaffirmthatlamexemplfromlhe Contradarb Li.nw Lawforthe
pp 'following mason.(Section 7031.5,Business and Piofessions Code:Any city or TIME.METLR OR POLE INST. o
L -
anystm mpriulmaaperancearoteud,alttheaprovgdemdbhper tt
Q�( any stmdure statrtolement
that he b,also sed pursuant t the rovitd hperf t e POWER DEVICES
file a signed License
( he is r 9(cod punting it the tion Moss of the '
3" star3Controf the
Mcensc Lew rodesser9(mm)or that withxemadherefof and
OCi SWIMMING TOOL ELECTRIC
slon3o(lhe Nusinnssand Profemlons Code)orlhat hebexem thercfromand � VALUATION. '
h Qthe basis far the alleged exemption. Any violation of Section 7031.5 by any . OUTLETSSWITCHFSFTXTURES
5� applicant fora permit subjects the applicant to a civil pemlty of rad..than
mL"c five hundred dollars(S500). NEW RESIDEN'IIAl ELECTRSQ.Fr.
r_1STOWS . TYPE CONSTRUCTION
G((ilil7 I,as owner of the property,or my employees with wages as their sole
compensation,will do the work and the structure b not Intended or offered for
sale(See 7014,Business and Professiow Code:The Contractors License Law
r3$ does notapplylo an owner of property who Wilds or lmprovestherron,and OCC.GROUP RFS.UNITS '
who does such work himself or through his own employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebullding or TOTAL:
Improve ntfi; withinoneyearofcompletion,theowner-WRderwill have .. -
enol proving that he did not build or Improve for purpose of sale.), QTY, „t o'k(J7VIBING PERMIT t'' t� ' 'FEE s' FT.ODDZONE APN
1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
.at ors to construct the project(Sec 7094,Business and Professions Code: - -
The Con dors License Law does not apply to an owner of property who - ALTER-DRAIN kVENT-WATER(EA)
Wild, or Improves contracts
thereon, and who for such pmjem with a - DEVICE FEE.SU151= MMARY
'
ca)licensed pureuant to the Contrador's License Law. -
exempt under Sec. - B k P for that recon SACK FLOW PROTECT. —
DRAINSFLOOR.ROOF,AREA,COND. SANITARY Y N
Owner Date - RECEIPT X
WORKMAN COMPS-NSATION DECLARATION FDn`URES PER TRAP SCHOOL TAX Y - N
❑I hereby affirm that I have a certificate of consent to self-Insure or a RECEIPT N
,. urbficaleofWorkers'Comperuatlonlvumnmoramdifted copythemof(Sec. GAS FA.SYSTLM-1 WC,90UILETS PARK EEE Y N
3500,Lab C.) _ —
Policy X RECEIPT N
CAS EA.SYSTfM-0VER d(TAI
' Co any � � - BUILDING DIVISION FEES
., �Certlfled copy Is
❑ hereby fumished.
Certlfed copy is with y inspection division.divlalon. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWf:R-SAMTARY-STORM EA.2001sT. Date RCtt'1 t#
(Thlasectlon need not be compiled if the permit isfor ode hundred dollars
(5700)Offy that
tP WATER HEATER W/VENT/ELIDCTR ENERGY FEE Y N
Ill not that o any Pehe rson
an the work so as to b co eermlt b Issued,the
I shall not employ any person in any manner so ns to become subject to the
Workere'Compen9atlon laws of California. WATER SYSTEM/TREATING la.Date - - PAID '..
O Z Applicant NEWRESIDENTIALPLMB, SQFf. Date Recei 1#
Z O NOTICETO APPLICANT.If,after making this Certificate of Exemption,you
Hshould become subject to the Workers'Compessation provisions ofthe Labor TOTAL:
Code,you must forthwith comply with such provisions orthis permit shall be
W > deemed revoked. 'BUILDING FEE .
dCONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby affirm that them ba construction lending agency for the pxrfmm� TOTAL: ELECTRIC FEE
Z anu ofthe work for which this permit fix Issued(Sec.3(197,CIv.C.)
U O L<iudees Name „ PLUMBING FEE -
1L F Lenders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfy thatl have mad thbapplicationand alatethattheaNwe Information
a Iscorred,lagreetocomply.withallcityand mdntymdlnanmsand datelaws PORMLTISSUANCE FEES PAID:
} mliAlogtobulldingconstrudion,and herebyamhmive reprexntativesofthls
F N city to enter upon the above-mentioned!Property for impection purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an d keep harmless the city of C.ImA1 o Date Receipt#
O against lUbI es, gi nN,Inst dexp noes which nuy In any yaccrue AIRHMVOI1NGOMT(TOI0,000CFM) SUBTOTAL:
against seldC o or of ire gre rating of Nisp l� /�(� AIR HANDLING UNIT(OVER to'cori 1M) CONSTRUCTIONTAX
S wmreoA nl eoRDOUSnirador ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
- A2AMATER IALS DI SCLOSU RE
'Will thea caat or future building occupant store or hind le haiardous I IFATING UNIT(It 100,000 BTU)
Date - Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the —
I lealth and Safety Code Section 25532(a)? HEATING UNIT(OVER Wg000 BTU) TOTAL:
❑Yea r]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) - ISSUANCE DA'Z'E
which emit hamnlous air contaminants as defined b'y the Bay Area Alr
Quality Management District? BOILER-COMP OHP OR 100,00(l BTU) ;
4 Yes n No
have read the haza`woudamaterlals regWrements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Glifomia Health&Sa! yCode,Sed 1ov 25505,25533 and 25539.1 ICI(7� �T 1144,
understand that if the building does am ass rromly have a tenant that itis my NEW RESIDE TIAL MECH. SQ.FT. f�
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. - - 14,n . •4,4 ('
Owner or authoriud agent Date - ISSUf:D BY SiRX9L+Cl
TOTAL:
OFFICE COPY