22515 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification - - PERMIT NO.
Building Address:
i5$b As Vey- L-q,et er+N\V 22515
��l w-" 6r a.X Mittel" 2 _S--1319 CITY OFCUPERTINO-BUILDINGDIVISION 7O
Architect/Engineer. Lie.No:
Contractor:Name: Lic.No: APPLICATION I PERMIT
BUILDINC-ELECTMCAL-PLUMBINGMECHAMCAL CATEGORY CONTROL X
ELECTRIC PERMIT ;!FEE BUILDING PERMIT INFO'
Address:
P[RMITISSUANCE 1:1 ❑ 11LICENSED CONTRACTOR'S DEC W RATION
IMrcby efirmthat l amlicensed under prwlsionsofChapter9(comerere APPLIANCES-RESIDENTTAL JOB DFSCRI'IION
o gwlth Section 7000)of DlvUlon3 ofthe Busfoessand FrefessimoCode,and m
license is1.full force and effect. PANES ��r r
License ClaUss Lk11/0krt_IPI lV
Date ContractorUP TO 200 AhIPq
ARCHITECTS DECLARATION 201-1000AMPS
1Q+�Ore Zp l understand my plans shall be used as public rectuds OVER 3000 AMPS SQ.IT.FLOOR AREA S/SQ.PT,
E z Licensed Professional SIGNS ELECTRICAL
GG 6� OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
z 1 herebyafBrmthatlamexempt fmmthe Contractor'sLlmnee Law forthe
� O following mason.(Sectme 7031.5,Business and Professions Code:Any city or q•pMp MET1R OR POLE INSf.
P f' countywhichmqulmapermittocorvtmd,alteplmpmve,demolhh,ormpalr
445 aanystru "pdortoim Wuance,aLsorequimsiheapplicantforsuchperMtto
L`O c.V file a signed statement that he U licensed pursuant to the provisions of the POWER DEVICES
Contractor's License law Chapter 9(commencing with Section 7000)of Dlvl- SWIMMING POOL ELECTRIC 01 sion3ofihe Businessand ProfenionaCode)orthathebexemptthemfmmand VALUATIONO
S°•3] the basis for the alleged exemption. Any violation of Section 7031.5 by any D
p;o OUTLETSSWITCIiES
Applicant fora permitm
subjectathe applicant to a civil penalty of not room than FIXTORES
five undred dollars(S500). NEW RESIDENTIAL RLECTR
Q 7 I,as owner of the property,or my employees with wages as their sole W SQFr. STORIES 'TYPE CONSTRUCTION
c
,actuation,will do the workandthe structure U not Intended or offered for
O saIn6ce.70K Business and Prodedoru Code:The Contractors License law
S� do...&apply to an owner of property who huilds or improves thereon,and
RIS.UNHS
OCC.GROUIs -
who doessuch work himselforthrough his own employees,provided that such
Improvements are not Intended oroffered for sale.If,however,thebullding or TOTAL:
Improvement lssoldwlthinoneyearofcomplMIogtheowner-buRderwill have
th;*oden of proving that he did out bund or improve for purpose of sale.). QTY, PLUMBING PERMIT FEEplgpOZONE APN
IJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSIIANCE
contnctara to construct the project(See,7014,Business and Profeaslom Code:
The Contractor'.License law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER CEA)
Wilda or Improves throne,and who contracts for such pkajeis with a
cgp[Iadoes loused pursuant to the Contractor's License Law. — FEE SUMMARY
Ll I am exempt under Sec. B k P C for thismason BACK FLOW PROTECT•DEVICE
CUTS I UP FEES•
Owner Data DRAINS-PLOOR ROOF,AREA,CONO SANITARY Y_ N
WORKMAN COMPENSATION OECLA =
Of
hereby RATION RECEIPT
affirm that 1 have a cortffkate of consent to ArIFImm ,or a FDCTURES.PER TRAP SQi00L TAX Y N
certificate of Worksm'Compensation Insurance or a certified copy thereof(Sec. RECEIPT X
3810,Lab C.) GAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N
Poll X _
Co any GAS EA.SYSTEM-0VER4(EA) RELEITM
MCertified copy U hereby furnished. BUILDING OI VISION FE I'S
❑Certified copy U filed with the city inspection d lvislon. CREASEANDUSIRL WASTE INTERCFPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID �`3D
COMPENSATION INSURANCE SEWER-SANITARY-STORM pPIOed ifthepermltlsforonehundmddollam SANITARY-STORM EA.20017. Date Receipt#
(81Ieoiless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I ll not that o Any person I any co weak for which co a rmitsubject,
ct to thi —
I shall not employ any person In any manner ro u to become rtebject to the Z WATER SYS TEM/TREATING PAID
Workeei Compcnsatlon Iowa of Gllfornh.Date
O Applicant
Z O NOTICETO APPLICANT.If,after ma king this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFr. Date Recei Hf
fshould become subject to the Workers'Compensation provisions of the Labor TOTAL:
W Code,you must forthwith comply with such provisions or this permit shall be W -BUILDING j dressed revoked. - ...
a C CONSTRUCTION LENDING AGENCY
Z EH
C SEISMIP
I hereby a(Rren that there Us dom uction lendingagency forthe penin SEISMIC
FEE
anceofthe work forwhich this permit lalawed(Sec.3097,CIv.C3
V O Lendd.Name ul• PLUMBING FEE
LL F Lender.Addmss MEC 'NI LA'L P RM FEC •
OWIcedlfylhatlhavereadthbappl��tionandslatethattheabovelnformat) . MECHANICAL FEE'
// /� t�
S Is osimet.I agreeto comply with all city and county ordinances and state la s 'PERMITIS$(Tfl�'C FEES PAID:
>. W milling to building construction,and hereby authorise representatives of( is
I— Z city to enter upon the above-mentioned property for inspection purposes, OR ADD �'1-I
agree to save,Indemnify an d keep harem the City of Cupro t o Date •Reoeiptlt
Bablllors,judgments,rorty and expenses which may In anyway. AIR HAh� SUBTOTAL:
aga. iis�eld Cityincon nre of the granting of this pemnit.
(�. OyQA 7/jam/C�I NR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle haaardous HEATING UNIT(TO 100,ODDBTU) Date RCCCI IN
material as defined by the Cupertino Muedcipal Code,Chapter 9.17,and the -
HealthandSafetyCode Sectioa75S32W7 HEATING UNIT(OVER 100,000 BTUs.❑ TOTAL:
Yes No •
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit haaardous air romaminants as defined by the Bay Area Air
. Quality Management District] BOILER-COMP Diff'OR 100,0110 BTU) .
Yes ❑❑No
have mad the haraedo.a maP1q�p
terials requiremorts under Chapter 6.95 of BOILER I00,00D BTU)
the California Health&Safety Code,Sections 25505,25533and 75534. I _ 1111 A
Q
understand that if the building docs not currently have a tenant,that It is my NEW RESIDENTIAL MECH. S'Q.FT Yfm, Y V
responsibility to notify the occupant of the requirements which most be met
prior to issuance of a Certificate of Occupancy. ' "
Owner or aulhodaN agent Date ISSUEDBY:_"Uy
TOTAL:
OFFICE COPY