22840 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMRNO.
Bullding Addreso
--7(0 LPrw E 22840
one:
y� oAum R t7L � (�Q CITYOFCUPERTINO-BUILDING DIVISION D
tm r'sN Lic.Na r�
il-milHyde Cs �x pJ APPLICATION I PERMIT CATEGORY Co OLY
lieBUILDING-ELECTRICALPLUMBINC.MECHANICAL
Architect/Gglneer: y��
QTY1ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrear
PERMITISSUANCE E:1 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyafftrmthatl am licensed under provisions of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwlth Sectio� '
nl�70r0c0e)oaaf Divtgon3 ofthe Buslrraasand PrefessionsC-ode,and my
license is In fuVt Pi eff Y. PANELS _
Licenv Chu(j+i1 - r� � C
Date a Contractor
✓G/I CHITECI`S DECLARAT 201-IODOAMPS
fl70 I understand my plaru shall be used as public records. OVER I OOO AMPS Re.SQ.FT.FLOOR AREA S/SQ.FT.
�j Licensed Professional SIGNS ELECTRICAL C D ' N
G� OWNER.BUILDER DECLARATION SPECIALCIRCUIT/MISC � �
owing rasormthatiam cumptfroossa Contractor's License Law for the
following mecto Business and Professions Code:Any city it
O TEMP.METER OR POLE INST. / /
p� county which requlresa pertNttoconatruct,alleglmprove,demolish,orrcpalr
gg'' a any at rutlurctatemeltshaa he
alcensed pursuant
provisions
of the POWER DEVICES Q /�
V file a signed statement that he V licensed pursuant to the proal Toru of the
30t� Contnctor's License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
El d..3ofthe0usinessand PmfeviomCode)orthathehemmptihemfmmand VALUATION
O the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETSSWITCHESRXTIIRES I a O—0 s a.►
appilant fora permit subjects the applicant to a civil penalty of nut room than v7 v
five hundred dollars($S00). NEW RESIDEN7TAL ELECTR
n I,as owner of the property,or my employees with wages as their sole SQ'Fr' STORIES TYPE CONSTRUCTION
Mcompensation,willdothe work andthegructure is nutimended or offered for
sale(Sec 7M7,Bustrresa and Profmlou Code:The Contnd.e.Limrue law
(,I�$ don not apply to an owner of property who builds or improvn thereonand OCC.GROIR' RFS.UNITS
CC.• whodoeasuchworkhimvlforlhroughhisownemploym,providedthatmch
Improvements are not intended muttered fosale.If,however,thebullding or TOTAL:
improvementbwldwithlnoneyearofmmplellomtheawner-budderwill have
t1gjIurden of proving that he did not build or Improve for purpose of ssle.). QTY, PLUMBING PERMIT FEE
L as owner of the property,am exclusively contracting with licensed F7.00D ZINE APN
contractom to corotruct the projed(lim 7074,Buainevand Prfevloro Code: PFRMITISSU'NCE
The Contractor's License law don not apply to an owner of property who
Wilde or Improves thereon, and who contracts for such pipjects with a ALTER-DRAIN&VENT-WATER(EA)
odor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L�I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE nu
Owner Date DRAINSFLOOR ROOF,AREA,COND. SANITARY Y_• N—
PT
_WORKMAN COMPENSATION DECLARATION RECOt'fY
QI hereby affirm that I have a certificate of consent to self-Irnure,or a FD(TURFS PER TRAP SCIiOOL TAX Y N
certifloteof Workers Comperuatlanituuranreorra certified copy thereof(Sec. RECEIPT af
3800,Lab CJ ! GAS FR FA.SYSTEM4 INCA PARK FY_ N_
policy RECEIT Y
Cam any_ CAS�EA.SYSTEM-OVER 4(EA) B UILDING DI VI SION FEES
K2Cerll(le cop 6y m ed.
�Certlfied copy V filed with the city Inspection division, CREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION Icpcmut f. SEWER-SANITARY-STORM EA 200FT Date Recel t#
(This wctlon need not W completed I(Ihe permit V Corona hundred dollars
($100)orlea.) WATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
I certify that o the person In any m wok so as t ob co permit c issued, —
I shall not employ any person In any manner w as to become subject to the WATER SYSTEM/TREATING
Workenvll
'Compenon fawn of CaBforNa. Data PAID
O Z Appllant Date Recei IN
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RRSIDFNDAL PLM B, SQ.Pf.
should be..subject to the Workeri'Compemation provisions of the Labor TOTAL:
N Code,you moat forthwith complywlth such provisions orthis permit shall be
7 deemed revoked. BUILDINGFEE .00.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihembyaffirmthat there Is a construction lending agency for the perform- ELECTRIC FEE
M Z arm ofthe work!or which this permit is Issued(Sec.3097,Civ.Q - TOTAL:
U O Lender.Name PLUMBING FEE
LL H Undee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W lomifythmlhavereacitia; ppliati...ndaatethattheaboveinkmonion
Isemmet.I agree to comply with alldtyand countyonllnanmand gate laws PETMITISSUANCE FEES PAID:
} 1 relating to building construction,and hereby authorize representatives ofthla
?N city to enter upon the ab....U..ed property for Inspection purposes. ALTER OR ADDTO MOCK
(We)agree to ave,indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against liabilities,Pcigmems,cogs and expenses which may In any way accrue AIR HA NDLNG UNIT(TO 10,000 CFM) —SUBTOTAL:
ag irut old City nsZ ce ofthe gr ming of this permit '
�( (� AIR HANDENGUNIT(OVER IO,ODOCFM) CONSTRUCTIONTAX
(sL p�.. 0
1 Signature oTApp�Co'ntrtlor Late, EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HFATINGUNIT(TO100,0DOBTU) Date nuterialasdeflned by the Cupertino Municipal Code,Chapter 9,12,and the Recel tN
Health and Safety Code Section 2SS32(a)T HEATING UNIT(OVER 100,000 BTU) - TOTAL:
❑Yes No
Will the applicant or uturc building occupant use equlpmenl or devicoe VENfILA'NON FAN(SINGLE RESID) IS 9�,I�DATE
.which emit harardous air contaminant.as defined by the Bay Area At,
Quality Management District BOILER-COMP OHP OR 100,IX10 BTU)
Yrs ��''7Us ars a��•
have read the hazardous nuterials requirements under Chapter 6.95 of BOILER-COMP(OVER IW,000 BTU)
the California Health&Safety Code,Sed ions 25505,25533 and 25534.I as�/a�� ,,{T
understand that if the bu llding does not currently have a tenant,that It fs my NEW RESIDENTIAL MECH. SQ.IT. C{y YJ WpaslK
responsibility to ratlly the occupant of the mqulrements which must be met 4 Yi Y7k
Prior tt000 brass ance ofa Certificateof Occup'my.
Owndr or authorlud agent Date ISSUED BY:
TOTAL:
OFFICE COPY