22330 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PELVIT NO.
Building Address: - 2 2 3 3 0
a,2
1,20 O C� .
e: A
ner • ,�`$- on_�j3 . CITY OF CUPERTINO-BUILDING DIVISION
Cc tract rN y LIc.No: APPLICATION /PERMIT
Se.�u d/I—n—i eLS�975— BUILDINGELECTRICAL,I^UMBINC-MECHAMCAL CATEGORY CONTROL M
Architect/Engineer. &7 Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERIATISSUANCE El F-1 El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commonc. APPLIANCESRESIDENTIAL JOB D65CRI"DON
tngwith Section 7000)forces d delon3olthe Busineasand lhvfnslomCodc,and m
license le In full form and e((eR. p PANELS
Lima-
Date
` I
Date_ ContranorS;f' UP TO 200 AMPS
ARCNITECPS DECLARATION 101-1000 AMPS
q�q�uu ceO Zp Iunderetand my plans shall be used as public records. OVER IOW F7.OG AMPS SQ.FT. OR AREA S/SQ.FT.
h:Z Licensed Professional 51GNSELECTRICAL I N
<<�6 OWNER IL
-BUDER DECLARATION SPECIALCRCUIT/MISC
7s, 7 Ihercbyaf(Irmthat lamexemptfromthe Contractor'sLlcerseawforthe
pp ^ following remain.(Section 7031.5,Business and Professions Code:Any city or n 11
O 2 y u� TFMI'.MEfE[i ORPOLE[NST. eVe
F,� countywhlch rcqulrcaa permittomnstrun,alter,lmprove,demolhh,.rrcpalr ,
q .a anystmn mprartolbW ancgaLsorequimtheappBeantforsuchpermitto POWER DEVICES
f5 O e. file a signed statement that he Is licensed pursuant to the provisions.f the / 1
FWj q Cordocwra License Law(Chapler9(commencing with Section 7000)of Dlvl- d —/
�Ot slon3ofthe Bus msand ProfemlonsCMe)orthatheaemmptthemfmmand SWIMMING POOL ELECTRICAr
VAI. ON
< the basis for the alleged exemption. Any violation of Section 7031.5 by any Of1TLE7SSWITChIFSHXTURLS
appu..t fora pemdt subjects m
the applicant to a civil penalty of me ore than
five hundred dollars(9500).
I,as owner of the roe NEW RESIDENTIAL ELECTRSQ.FT, STORIES TYPE CONSTRUCTION
7 6 property,k,a air my employees with wages r !fere sok
compensation,BmIre the work and Prohe fessions
eh not Contractors
or offered for
❑ sale(Sec.apply
to alnow and f property Code:The Contractors License Law
$$ whododoes tapchwork unser ofpropertyo nemporlmprovnthercoryand OCC,GROUP RES.UMTS
whodoement.a orktInten Intended or
hleowne.If,hoeeprovided that
improvementsarenot Intended esro(co for sale.If, carver-q deerhe ba ill haveding or TOTAL:
Improvement hwld within one yea mfcompinloR the owner-bu0derwBl have
t rden of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOODZONE APN
LI,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
comracters 1.consUuct the project(Sec,7074 Basin..and Professtom Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VEM-WATER(EA)
builds or Improves, ere
thereon,and who contracts fee such pRojects with a
ntactor(s)Ilemsed pursuant to the Contractor's License Law. BACK FLOW PROTFLT.DEVICE FEE SUMMARY
E]I am exempt under See. B k P C for this mason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT p
WORK MAN COMPENSATION DECLARATION FIX7VRF_S PER TRAP SCHOOL TAX Y_ N_
[ I i hereby affirm that I have a I rt rare of consent to opytheure,or . RECEIPT N
re Ilcatecco(�Workery Comper/wltlonlnsuranre.racertilied copythereo!(Sec. GAS G.SYSTEM-]INCA OUTLETS PARK FEE Y N
E.Bi abSV y D Gaal— I, RECEIPT Cairn acv GAS EA.SYSTFN-OVER4(EA)
Q4 O BUILDING DIVISION FEES
[QCemned copy ts herebyfurnished.the city
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
eTCerti(led copy V(fled with the ctty ins)rectlon division.
VL CERTIFICATE OF MEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCEMe SEWER-SANITARY-STORM EA.I00FT. Date Remi tri
(Thor section need not be completed If the permit Meters hundred dollars
( Sec00)a! (h WATERHEATIRw/vENT/ELECTR ENERGY FEE Y N
Icertllythat In the Performance of the work forwNch this permit Is Issued, —
I shall not employ any Person In any runner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Dale PAID
Z NOTICApplicaE
MNEW RESIDENTIAL Pi SQ,HT. Date Rcml tN
Z O NOTICE TO APPLICANT: after making this Certlllote of Exemption,you
should become subject to the Workers'Compensation Provbloes of the Labor TOTAL:
I�) Code,y.0=at forthwith comply withsuch provlslonsairthis permit shallbe B�I D FC
`> deemed revoked.
W O CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby&film that there U a mmtrunion lending agency for the perform ELECTRIC FEE
7 Z anceoftheworkhrwhlchthispermitis issued(Sec.3097,CIv.C.) TOTAL:
U O Lenders Name PLUMBING FEE
LL H Lender's Adde ss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icertlfythatl haveread this application and slatethatthe above lnformatlon
IL 6cormct.lagmeto comply wlthallcityand countyordlnanmand nate laws PERMIT ISSUANCE FEES PAID:
relating to building construction,and hereby authorize representatives of this
I— 2 city to enter upon the above-mentioned Property for Inspection purposes. ALTER OR ADD TO MECH.
(We)agree to we,Indemnily and keep harmless the City of Cupertino Date RCCeI tN
V against liabilities,jodgments,Certs and expenses which may In anyway accrue AIR HANDLING UNIT 0010,000 CFM) SUBTOTAL:
ag.reat saI ty in onecri ear of the anon of thl.Penn]
_ r.q AIR HANDLING UNIT(OVER 10,000CIM7 CONSTRUCTION TAX
Ignatureo pplicant/Contractor Date / IXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapplinsnt or future building occupant smreor handle hazard... HEATING UNIT(TO 100,000 BTU) Date RCECI t#
material as dell nM by the Cupertino Municipal Code,Chapter 9.11,and the
Health and SafetyC^de cion]5531(a)7 HEATING UNIT(OVER 100,000 BM TOTAL:
Ycs No
Will the applicant o for um building ompant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE
which emit hazardoua air c ntamlmnte as defined by the Bay Area Air
• Quality Management District? BOILER-CAMP OHP OR 100,000 BTU)
N.
I Yas �ety 91991
have mad Health
a awmode, etion,2mentsunderChapter.1 o! BO[LEA-COMP SEP
the California l9ealthk Sof Code,Sections 2550.5,75533 and 75534.1
understand that if the building does not currently have a tenant,that it is my NEWRISIDFNTIALMECH. SQ.FT.
responsibility to not lfy the occupant of the requirements which moat be met
pri 1^Lssuancoof/a/Ce 1 ate/9l Occupancy. p,yy of
rl
ner or authorized agent Date TOTAL: ISSUIiD BY�Aa
OFFICE COPY