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APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification -
Building Address:-
ock ��s�
PERMITNO.
22032
�w7ne�r ,, •came: one:
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-
CITY OF CUPERTTNO-BUILDING DIVISION
APPLICATION /PERMIT
BUILDINGELFiCTRICAL-PLUMBING-MECHAMCAL
A
r�(
CO
aa�aoraNamlee: - Lie. No:
�V " �d�SLrr'�'�\'` � r
CATFCARY
CONTrLap G-2
c'C.
(Y �D C,
Architect/Engineer.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
- -
Address:
'
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby on7OOOffirm atlamsim3 fthe Bu iprovisionsoteskmsr9 (mmmene-
IngwRh Section force afdefeon3o(the BualneseandProfesponeCode, and my
Ilcenx Is In s force and died.
License Clam Lic.pl�P�
Date Contndor -UP
APPLIANCESRESIDENTIAL r
JOB DESCRB'TION
• `
1
PANELS
TO 2DOAMPS1
201-I000 AMPS
ARCHITECT'S DECLARATION
Iundentandmyphos.hxHb .edaspubgerecords
Licensed Professional
OVER IWO AMPS
SQ. FT. FLOOR AREA -
S/9Q.Fr.
SIGNS ELECTRICAL
OWNER -BUILDER DECLARATION
I herebyafOrmthat l arm exempt from the Contractor's License Law for the
following reason. (Section 70313, Buish ess and Pmfealon. Code: Any c ty or
coonlywhich requiresa pemJttoementrud, alteq improve, demelbh,or repair
anystrudure prlortofta issuance, also requhresthe appllcantfor such permit to
file a signed statement that he is Ilmnaed pursuant to the provisions of the
Contractor's License Taw (Chapter 9 (commencing with Section 7000) of Divi-
slon 3 ofthe Business and Pr f.mlomCode) orthat he t exempt therefromand
the basis for the alleged exemption. Any violation of Section 7031.5 by any
applicantintopermit subjects the applicant to a civil penalty of not mare than
five 1, as ed owner of he pr .
❑Las owner of the property, it eery employees with wages thele dole
d for
compensation, Businessl do and
sale (Sec. Business Cade: The
Pmf dthe et odure le Contractorot Intended or License
License law
Law
C
�^ .
LITER
SPEC1ALCIRCUIT/M15C
TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
VALUATION
Z�t�S,
3 OUTLETSSWITCHESFIXTURES t
r
NEW RESIDENTIALELECTR SQ,FT.
STORIES
TYPE CONSTRUCTION
to rops ty
apply f Propertyor mil eves
does nortsuchwrk owner offprough hisonempoyees,punted that such
who does
ments ars
Improvement are not Intended orofferect foreale. IL howevep thebuliding or
dedoroughhi.owne. If, prate dthatsuor
Improvement issold withinoneyearofcompletion,the owner-bullderwill have
en owncvingthathe did rrM build orimprove for purpose of sat.).
owner of the property, em excluelvely contrading wkh Ilcenxd
L
retractors to cowtmd the proj¢at (Sec.70i4, B e'tama and Proteealors Code:
The Contmctol. Llcena Law dcea not apply to an owner of property who
W aids cr Improves thereon, and who contracts for such p(o)ects with s
��[aactor(s)Banaed pursuant to the Contnda's License Law.
u1 am exempt under Sec B k P C for this reuon
TOTAL:
'
QTY. PLUMBING PERMIT FEE
,(JCC. GROUP
RFS. UMTS
( PERMIT ISSUANCE 1� D
ALTER -DRAIN & VFM-WATER (P.A)
FLOOD
APN
BACK FLOW PROTECT. DEVICE
FEE SUMMARY
Owner pm
DRAINS FLOOR ROOF, AREA, COND.
FIXTURES PER TRAP
SANITARY Y N
RECEIPT It -
WORXMANCOveacomTIONOECWRATION
❑I hereby ora
that I have a certHbate o! concent to opy
SCHOOL TAX Y N
orkemaffirm
artlflatoo/Workers'Compersatlonlnsurance oracertl(led mpythereof (Sec.
thereof
38011, Lab CJ
Poliryp -
RECEIPT #
GAS PA gyyTEM-11NC,4 OUTLETS
PARK FEE Y N—
RECEIPTIf
Com any
❑pCertlfled copy is he d withthecitfurnished.
❑Certuied copy is filed with the airy inspection division.
GAS EA. SYSTEM-OVER4(EA)
GREASE/INDUSML WASTE INTERCEPTOR
BUILDING DIVISION FEES
PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS'
GREASE TRAP
9i
PAID" ' -9i
I
ceCOMPENSATIONNSURANCE
(Thlectlan need not be comp) TI Npermine ttforohundred dollen
($100)orl..)
a
I rttiythat In the pelf mompe.fthework forwhich this permit is Issued,
I shall not employ any person In any manner so as,to become subject to the
Workers' Compensation Laws of California. Data
ApplicaNOTICE
NOTICE APPLICANT: after king this Certificate of Exemption,
Date Recel t#
\
SEWER-SANITARYS'RJRM EA 'dwFr
WATER HEATER W/VENT/dECTR
ENERGYFEE Y N
PAID
Date Remi t#
'
7TWA.pDM SYSTEM/TREATING 0
NEW RESIDENTIAL PLMe. —SQ.FT.
you
oo
shoulu at er a pro
Coat youvoet(orthwlth comply with such provislars orchis permit shall be
it the Workers' such provisinpro this permit of s Lab be
darned revoked. �
'
.TOTAL:
BUILDING FEE -
TOTAL: _D'�
CONSTRUCTION LENDING AGENCYSEISMIC
Ihenbyaffirm that there is a construction londingageuy for the perform
arm of the work forwhlch this permit is Issued (Sec. 3097, Civ. C.)
ixader'. Name
Leader'. Add..
Iceklfythatlhavereadthieapplicatbnandstatethattheabovelnfor him
Is correct.I agree to comply with all city and county ordinances and pate laws
relating to building coertmotion, and hereby authorize representatives of this
city to enter upon the above-mentioned property for inspection purpose..
(We) agree to save, Indemnify an d keep harmless the City of Cupertino
agalrst liabilities, copdand expensed which may in anywayaccme
agai Clty In conaequ na granting ft epermit. I
FEE
ELECTRIC FEE.
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
-1 ifs
PERMIT ISSUANCE .(r.OV
ALTER OR ADDTO MECH, �Q Q
AIRHANDLING UMT(TOI0,000CFM)
MECHANICAL FEE
. a
FEESPAID:
Date Receipt#
SUBTOTAL:
OQ
-AIR HANDLING UNIT (OVER l0,000CFM)
CONSTRUCTION TAX
i Allan /Co r at
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCD
CONSTRUCTION TAX PAID:
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupant store or handle h ardo..
material as defined by the Cupertino Municipal Code, Chapter 933 and the
Health and Safety Code Section 25532(a)?
❑ Yes No
Date Recei t#
HEATING UNIT (OVER 100,000 BM
-
-'TOTAL:
-./h(
� ery/
VENTILATION PAN (SINGLE RESID)
ISSUANCE DATE.
Wiiltheappllcantor hire building occupant use equipment or devices
which emit hasardoud air contaminants as defined by the Bay Area Air
allty Management Dhe istrict?
Yee No
BOILER -COMP 0HPOR 100,000 BTU)
BOILE&COMP(OVER 100,000 BTU)
M of
havereaa Health
the Callfornla Health &Safety Code, Sectlore 75505, ZS533 and 75534. I
oet m d,Sorequinrrent5533 and 25534.
'
NEW RESIDENTIAL MECH, SQ.FT.
understand that if the building does not comenlly have a tenant, that it is my
responsibility to notify the occupant of the requirement which must W met
prior to issuance of a Certl0ate of Ocaupanry.
'
1YIV�T
MAY
ISSUED BY. i
Owner or authorised agent Date
TOTAL: D
OFFICE COPY