22681 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES--USE BALL POINT PEN ONLY
Building Pruect Identification • PiI4 TNO.
B.Bdinj iren:
' ooD l�,�� c _ 22681
cancra ams: p o
la'{I/j,` o —�g 8.� CITY OF CUPERTINO-BUILDING DIVISION Q
C.ntrador'.Name: �����"a ' ✓...�-+ 2 Lk.No: APPLICATION / PERMIT
C 19 BUUM
ILDINGELECnUCALPLBING-MECIIAMCAL CATEGORY CONTROLN
. Archlted/Engineer. Lk.Na.
QTY ELECFRTCPERMIT FEE BUILDING PERMIT INFO
Add. [� PERMITISSUANCE
' DECIARATIL ❑ � ❑ ❑
LICENSED CONTRACTORON
IherebyaffUm that l am Beamed under provislonso(Chapter9(mmmenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwlth Sedi.n7000)of Dlvisi=3.fthe Bualnessand Pro(esslansCode,and m
limale=ss(ul ontra PANELS S�
Limn Clan k.N if3 ( 8 J1 1 `
Data CoontrejYZI
ARCHITECTS DECLARATION 701-1000 AMPS f1SQ�,
X COC I understand my plans.hall be used as public rerorda OVER 1000 AMPS - _=r?_kTi•^"4YFA_--
F4�(I Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIALCItCUIT/MLSC J
x f., 7a Iherebyaffirmthatlam exempt from the Contractor's License Law for the (P"
p following reason.(Section 7031.5,Business and Professions Code:Any city or
09GF couTEMPMETER OR POLE INST -�
K ntywhlch requirnapertNtta consWd,alter,lmproverrok
,de .h,orrepair . . ,
anystmcture prlurto Its issuance,also require.theappllmnt forsuch permit to POWER DEVICES .p1 ' 1
O file a signed statement that he b licensed pursuant to the provisions of the
f�gj5 w Contractor's License Law(Chapter 9(rommendn with Section 7000)of Dlvl-
W 3 p B SWMWNG POOL ELECTRIC ` u -
ebn 3 of Buslneecand ProfessionsCode)orthat he b exempt there(romand VALUATION
6 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHPSEKIURES INA L
appaont fora permit subjects the applicant to a civil penalty of not more than
five 1,as
dollars rofthe DOLpro NEW RESIDENTIAL ELEC'fR SQ.EF, M
UCTION
❑compe s owner of the property,or my employes with wages r thele sok fivehndred ollthe workandthestructure Vnot intended or offered(or
sale(Sec.7004 Basinsand Professions Code:The Contractors License Lawdoes not apply to an owner of property who bu lids or Improves thereon,and
who doessuch work himself orthrough his own employees,provided that such _ S
improvements arc not Intended orof(ered for sale.If,however,the build Ing or TOTAL:
Improvement is sold within one yearofcompletlon,the owner-builderwlll have
tlW.Iturden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
Lj FLOOD"LONE APN
L an owner of the property,am exclusively 04,Business
contracting with licensed
ode: Papp ISSUANCE
The
etractors Contrato consWctthe project(Seo apply
to
of prsiomoperty
Code:
TM Contractor's License on, does h apply tct en owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts (m such plojern with a FEE SUMMARY
"El"Ell m e empt pursuant m the Contractor's License P Law. BACK FLOW PROTECT.DEVICE
l am exempt under Sec. B &P C for this mason
OUTSI DE FEES
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
• Owner Date AECEM'N
WORKMAN COMPENSATION DECLARATION Fp(7�;PER TRAP SCHOOLTA% Y N
❑I hereby affirm that I have•mrt.rate of consent to opy thee,ore RECEIPT'M
c30D,LaeofWarken'Compensatlon Insuranceora certified copythereo((Sec. GAS F.A.SYSTEM-1 WGA OUTLETS PARK FEE Y N
3508,Lab C.)
Poltry M GAS E.A.SYSTEM-OVER 4(EA) RING DI N
Cam any BUILDING DIVISION FF.GS
vrertiled copy is hereby with the
city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
QyarttRm copy v nke with lne city Inspection division.
CERTIFICATE.OF EXEMPTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA Il10FT Date RCCEI tM
(fhis.ectlon need net be completed If the permit isforone hundred dollars
4 ($I00)orless) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that o the person ninny of heworkmanner so as to become
penultis to the
I shall not employ any person In any manner n n to become abject to the WATER SYSTEM/TREATING
Warkca Compenwtlon Lawn of Gllfomla.Date PAID
Z Z NOTICE
Applicant NEW RESIDENTIAL PLMB. SOFT. Date Recei t#
NOTICETO APPLICANT-. ahermakmnp .it.Certificate of Exemption,you
should become subject to the Worken'Compensatlon proal l.ns.(the Labor TOTAL:
P:
N Code,you mart forthwith comply wlthsuch provisions orthis perrrdbhall be BUILDING
W > deemed revoked.
d G CONSTRUCTION LENDING AGENCY SEISMIC FEE _
I hereby affirm that there Is a construction lending agency for the perform- ELECTRIC FEE
Z ante of the work(or which this permit is Issued(Sac.3097,Civ.C.) TOTAL:
U O Lendar'.Name PLUMBING FEE
W ~ Lenders Adore.. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OWI.Aifylhxtlhavereadthisapplimtl.nand data that theab.ve Information
R iscorred.I agreeto comply with alicityand county ordlnancas and stateiaws PERMIT ISSUANCE FEES PAID:
>. relating to building amstruction,and hcmbyauthoAacreprdmtativcsofthia
N
.r city to enter eaIxwaammlohad propertyforinspedlon purposes, ALTS(OR ADDTO MECH.
Z (We)aPlIe to e,indemnify an d keep harmless the City of Cupertino Date Rece1PIB
V against blllee., dgment.,coot de awhlchmaylnanywayaccrve AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
zgal .a1dC .dt 4t.encc of I anti this permit.
AIR HANDLING UNIT(OVER IO,000CIM) CONSTRUCTION TAX
Sinai. of Appllcan/C t.dnr Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
NA]A USMA v LS DISCLOSURE
Will lhcapplimnt or alum bullding occupant store or handle hoard... HEATING UNIT(TO 100,000 BTU) Date RecC' tN
material is defined by the Cupertino Municipal Code,Chapter 9.17,and the --
HealthandSafetyCodeSedo 32(x)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Ye.
Will theapplicentor tore bullding occupant u.eequlpment ordevice. VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hamrdom air rootami nua.definedbythe Bay Area Alr
. Quality Mansgement Dl rid BORFRGOMP PHP OR 11p,0008TU)
P4 Ys o
h read the haze .us rmleriaLs requlmmonb underChap(er 6.95 of BORE&COMP(OVFR 100,D00 BTU)
the Olifornla Health&Safety Code,Sections 25505,25533 and 75534.1
u nderst at iftheh docs not cv rrcmly haveatenanq that ithmy NEW AESIDFN7TAL MEC}T. SQ.FT ysly
res iblll ton the pant of the retulrcmenls whk mus be met lR
pito ante aCe to of Ocotpancy.
nor or horizeda nt Dale TOTAL: ISSUED BY..
OFFICE COPY
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30
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