22784 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ect identification PERMITNO.
BcWllng Address: 22784
16M 13 S B.4AF- Avg C:4'x�RT
weer• one:
ids i4R7I�- CITY OFCUPERTINOBUILDINGDIVISION
coetr.ctor.N.me: Lk.No: APPLICATION /PERMIT
�
A Its e k.No:
BUILDINGELECTRICATePLUMBINC-MECHANICAL CATEGORY CONTROL N I /
1010 ot�
1. QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add re PERTISSUANCE {.AI/ 1� ❑ ❑
LICENSED CO ACTOR'S DECLARATION• MI �-FJ
I hereby affirm that l area licensed under provisions of Chapter9(comment. APPLIANCESRESIDENTIAL JOB DESCRIPTION
ingwith Section 7000)o Divblon 3 ofthe Business and Professions Code,and my ,
Ricers Is In soli force and died. PANELS T
License Claw LICK `4,t
Date Contractor
ARCHITECTS DECLARATION 101-1000 AMPS
NO O. I..demand my plans.bsH be used as public records. OVER 1000 AMPS SQ.FT.FLOOR S/SQ.FT.
Fi �j Licensed Professional SIGNS ELECTRICAL Y�' � w
GG 1
6 OWNER-BUILDER DECLARATION
to
zp, [hereby af(irmtm ha[Iaexempt(romfhe Contractor's License Law for the SPECIAL CRTCUIT/MISC
following reason.(Section 70315,Business and Professions Code:Any city or
� t"'t�+ county which requires a permit to carutrue"ter,improve,dennlish,or repair ThMP'METER OR POLE[NST.
.au any structure prior toits Issuance,also requires lheappRcent for.uch permit to
U file a signed statement that he Is hcensed pursuant to the provisions of the POWER DEVICES
Contractors License law(Chapter 9(commencing with Section 7000)of DiviSpt SWIMMING POOL ELECTRIC
elOn3o(the Business and Professions Code)orthat he Wxe
em thercfromand �aasy���. a� VALUATION
the
0a basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXPURES aid
m applicant for a permit subjects the applicant to a civil penalty of not marc than
flue hundred dolUn($500). NEW RESIDENTIAL ELECTR ^.iQ.FI. STORIES TYPE CONSTRUCTION
nl,as owner of the property,or my employees with wages a their sole
compensation,wllldo the work ancithestmcture isnot Intended or offered for
O .1.(Sec.7044,Business and Professions Code:The Contractors License Law
j does not apply to ae owner of property who Wilds or improves thereon,and
F$^ who doeusuchwark hlmseBorthrough hisown employees,provided thatsvch OCC.GROUP RES.UNITS
improvements are not Intended oroffered formic.If,however,thebullding or TOTAL:
Improvement issold withinone)earofcompletlogtheawner-buiMerwiil have
rdcnot proving that he did nor build or Improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE —FLOOD TONE APN
as owner of the property,am exclusively contracting with licensed PERMIT) E
tractors to construct the project(Sec.7044,Business and Professions Code:
Contractors License Law does not apply to an owner of property who CALTER-D IN
Wild.or Improves thereon, and who contractp
s for such uojeos with a FEE SUMMARY
cgnjpcfor(a)licensed pursuant to the Contractor.License Law. BAIX T
L]I am exempt under Sec. B k P C for this reason
go I 1 -1 n r% OUTSIDE FEES
DRAINS-FLOOR ROOF,AREA,CO S RECEPTN TARP Y
Owner Date N
M
WORK AN COMPENSATION DECLARATION ' EC[OOL fAX Y_ N
❑I hereby affirm that I have o artlfmn of consent to s pythsue,ora BBC=N
380,Lab OfWorkeui Compensation[nsuranaora certi(kd copythereo((Sec. GAS EA.SYSTEM-I INCA OUTLETS FEE Y N
35110,Lab CJ '
Polity p RECEIPT N
GAS EA.SYSTEM-OVER 4(EA)
GEM BUILDING DIVISION FEES
Certified copy is herebyth the cid. - CREASE/INOUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy V filed with the city inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID C�
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."Fr. Date Reeel t `
(Thlssecdan need not be completed lithe permit infer one hundred dollars
($100).H.ss.) WATER HEATER W/VENT./ELECTR ENERGY FEE Y N
I certify that in the performance of the work for which this permit is issued,
I shall not employ any person in any manner ro as to become subject to the WATER SYSTEM/TREATING
Worken'Compewtlon Uwe.f 611fomla.Date PAID
z Z Applicant NEW RESIDENTIAL PLACE. SOFT. Date Recei t#
Z O NOTICETO APPLICANT;If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
F N Code,you must forthwith comply with such provisions or this permit shall be
W j deemed evoked. - BU N 'E
CONSTRUCTION LENDING AGENCY - SEISMIC FEE
d [hereby that tlsaconstmctlon lending agency 7,Civ. the perform ELEC'T'RIC FEE
� Z ante of the work(or whkhlhls perMtls Issued(&c.3097,Civ.CJ TOTAL: '
02 Ler ce.No PLUMBING FEE
LL F Lendsr.Addre.s - QTY. MECHANICAL PERMIT ISE
O W Icertifythat]have readthisappllcatlonand statethalthe above lnf.mation MECHANICAL FEE
R leconect.l agreeto complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
Meting to building construction,and hereby authorize representatives of this
)-
in
city to enter upon the abovernuttloned property for inspection purposes. ALTER ORADDTD MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino - Date Recel t#
O against liabWtic,judgeents,costs and expenses which may in any way accrue AIR HANDLING UNIT GTO 10,000 CEM) SUBTOTAL'
aga iqEt said City Inco ince of the granting.(this permit f AIRHANDLING UNIT(OVERl0,0XCPM) CONSTRUCTION TAX
C
Signature of Applicant/ tractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumre building occupant store or handle haaardous HEATING UNIT(TO 10,000 BTU) Date ReCe1 [#
material as defined by the Cupertino Municipal Cade,Chapter 9.1$and the -
He❑alt Yead Safety Code,Set icon 1SS31(z)? HEATING UNIT(OVER 100,0D0 BTU) TOTAL'
Will thexpplicant or❑future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID)
DATE
which which emlt hamedous air ormamlnsms as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 1(X1,000 BTU)
gave N No 9
averia ealth& Get materials Sereons255etsunderChapter.1 of BOILER-COMP(OVER 100,000 BTU)
theerItandt Health building
Cade, et currently have
a tenant
understand that if the building does not arrcntly have atenanL tbal ltEmy NEW RESIDENTIAL MECH.- SQ.FT.
ser toeollfyth occupant.(the equirerrcnts which must be met Gk ssata{{ ak
for to Ole ($wle parry. V71,Q/T�y
Ownercrauthariudag f Date TOTAL: ISSUED BY VCJF K
OFFICE COPY