22487 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PFRMITNO.
tlullding Addms:
/Di/ 7D l�H S'T AC,re- S 22487
nese came: - nna: APPLICA11ONSURME1 IAL D=
el We—I I eev— CITY OF CUPERTINOQBUILDING DIVISION q
cnntradnr .me: Lie No: APPLICATION / PERMIT
BUILDING-ELECTRICAL PLUMBINC-MECHANICAL CATEGORY CONTR L M
Architect/Engineer. Lk. o:
Z�9� C+ QTY ELECTRIC PERMIT FEE BUILDING PERMITINFO
y•tr
Address; 4-Ia'r� �, fl+p(WN PERMIT ISSUANCE Fill ❑ ElLICENSED CONTRACTOR'S DECW RATION
I hereby ef(Ism that lam llcmeed under provisions et Chapter9(commmn MPLIANCESRES[DENTIAL JOB DESCRIPTION
Ingwith Se on7OODof DlAslon3ofthe Bu.inesan'd/Professions Code,and my
It .ae m m fo m ana dred. y/N 7 PANELS f i9T 0pp C�GWQQ$V 2t
LlcenseC ® LIeN �O`Oa X �p /�sr
Date Contractor UP TO 200 ANTS
ARCHITECP9 10 201-1000 AMPS
p CO 1 understand my plata shall be used as public records. OVER IOW AMPS ./\ 1 . 77D
� SQ.Fr.FLOOR AREA r� � f/SQ.Fr.
Llceneed Profeslowl - SIGNS ELECTRICAL +. ' \ ;I r D I N
� a OWNEReBUILDER DECLARATION SPECIAL CIl2CUIT/MLSC ® -} ^ ., h �Y
ZF, Iherebyaffirm TOWNER-BUILDER the Contractor's License law fm the , I'11.i�'� Y
following reason.(Section 7031 S,Business and Professions Code:My d or /U T
ORP
F' countywhkbrequimape tww.tr M.1ter,impmve,de.lkh,orrepalr TFMP'METCf20ft POLE INST.
'y anystm=mpr rtoiwuance,alwrcqunmtheappficenl(msuchpemdtto
0 4 5 fits a signed statement that he h licensed pursuant to the provides,of the POWER DEV CES DATE
�O u Contractors License law(Chapterl?(commendng with Section 7000)of DIH-
O�p sion3ofthe BuelneneandPd..m uCode)orthat hehexemptthercfromand SWIMMINGPOOLELECIRIC VALUATION
<E
the basis for the allegedexemption. Any violation ofSection70315 more the.
OUTLET&SWITCHESFIXTTIRFS
applicant for aperMted exemption.applicant Anyvioation of Wtyo7031Sfrict by any
O five hundred delta.(S500).
'4..' I,as owner of the property,or my employees with wages as their wk NEW RESIDENTIAL ELECTR_SQ.FT. STORIES TYPE CONSTRUCTION
compensation,wOldolhe work and lhestructum is not Wended or offered for
O sale(Sc.7041,Busnnese and Professions Code:The Contractors License law
�$ does not apply toan owner of pmperty who Wilda or improves theme,and
e. who doessuchwork hlnselforthrough Neownemployeas,provided that such OCC.GROUP RES.UNITS
improvements arc not Intended orofferetl forsale.It,however,thebullaingor TOTAL:
improvementhwldwithinoneyearo(complml Ntheowner-builderwill have
t11RJZurden of proving that he did nor build or improve for purpose o(sakJ. QTY, PLUMBING PERMIT FEE FLOOD LONE APN
u I,ae owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contradoes to construct the project(Sec.7040 Business and Professions Code:
The Contractors License law does not apply to an owner of property,who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improve thereon,and who contracts for such pt-ojecm with a
ry1Rr+ctor(see)licensed Pursuant to the Contractors License Law. BACK FLOW I'It0?FLT.DEVICE FEE SUMMARY
LJ I am exempt under SB&P C for this reawnOUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Data RECEIPT'M
WORK MAN COMPENSATION DECLARATION FIXTURES PER THAI' SCHOOL TAX Y N
❑I hereby orfirmken that I have• Insurance
of consent to opythwrc,ora RFOEIPTN
certificate ofWorkers'Compersatlonlnsunncemacertified copy[herwf(Sec.
38W,lab C.) GAS,EA SYSFEMI INCA OUTLETS PARK FEE Y N
Policy M GAS EA.SYSTEM-OVER 4(EA) RECEIPT M
Cr3cny BUILDING DIVISION FEES
Certified copy is heed with to city GREASE/INDUSIRL WASTE INTERCEPTOR PLANC{{{,,,{{{���ppp3L[��TEE
Certified copyhflled with the city inspection division. r'7�y ` O,OQ
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE TRAP PAI Xys'r ) Z�
COMPENSATION INSURANCE SEWER-SANITARYSTORM EA IWFr D� Ote(D" Rece 61 L7
(Thhsedion need not be completed if the permit Is(mous hundred dollars
(E]W)or Tess) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
1 certify that o the pedourn in s(the wank in,as towhich co permit
subj a Weed, —
1 shall not employmaking manner at u m become subject to the
Workers Com f Dania. Data WATER SYSTEM/TREATING PAID
O Z Applicant
Z O NOTICE 7 A f, en thh Ctionpreo(Exemption,Labor
NEW RESIDENTIAL PLMB. SQFFr. DRIC RC 1 t#
Code,shoulyou
ma subjecttothe ply wit'CompemaHonprovhioes s par
lhs Labbe TOT L:
W N Codgyoumuat(orlhwlth comply with each provisions or this pemNbhall be BU a
> deemed revoked.
W G CONSTRUCTION LENDING AGENCY SEISMIC FEE t
1 Ihembyaffirmthat there h a comtmction lendlegagenry for the perform a
Zanxoftheworkforwhkhlhhpermilhhaaed(Sec.3097,CIv.C.) TOTAL. ELECTRIC FEE
(, O Landers Name PLUMBING FEE
IL H Lender'.Add ass QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I cedan
lrythatl have d thhappgotionand stetethatlheabovelnformation
Iscormd.l agmetocomplywnthalldtyand countyordinancesand state laws PERMIT ISSUANCE FEES PAID:
} M mIdIng to building construction,and hembyauthorize representatives ofthis
[— W citytoenlerupoo thc.Wve-mentioned property for inspection purposes. ALTERORADDTOMFCH.
Z (We)agree to save,IndemNly an d keep hamilm the City of Cupertino Date Reeel f#
I..I against liabWties,Jidgyments,costa and expenses which maynn anywayacwe AIR HANDLING UNIT CFO 10,0DO CFM) $UBTO AL•
agairstsaid Ci In. serye sof the gramin of thle pemdt.
�/ AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Sl naNrco(Appilesnt/ ontracto ox Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX AID:
HAZARDOU 1ATERIALS DISCLOSURE
IR the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rete t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I and Safety Code Section 75537(a)9 HEATING UNIT(OVER 100,00D BTU) TOT
M Yea No
Will the appllcam r tum Wilding occupant use equipment ordevim VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which snit haranlom air comarmna tse.defined bythe Bay Arca At,
Quality Management District? BOILER-COMP OHP OR 100,00t)BTU)
4 Yes g Na pin
have read the haza Dasa matedah rcqulrcrrcnb under Chapter 6.95 of BOILER-COMP(OVERIW,OW RTU) 4�
understand
talleslth&SafetyCode, on currently
have
tand75hatI1 -
understandthatifthebuieoccucesnotarrcntlyhavealenanLthatlthmy NEW RESIDENTIAL MFCi. SQ.IT imp�
responsibility to nolnfy the occupant of the requirement.which mat be met !T
pdort sac of Cent teof0¢upanry.
Owner or authorized agent TOTAL: ISSUED BY. W FWRNd�isse
C�+YL'1[�1I
OFFICE COPY
JOB FAN•.j i 21.t rt 5,n Aft . A'-1 SeR�r.s 3Pa
HYMll ENGINEERING SHEET NO. OF
3400 Kauai Court Suite #108
RENO, NEVADA 89509 CALCULATED BY DATE
Phone (702) 826.3019
Fax (702) 826.3076 CHECKED BY DATE
SCALE
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