22731 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'en Identification PERMITNO.
eAdd�, 22731
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a ante; , one: A
CITY OF CUPERTTNO-BUILD ING DIVISION
c°ntra ora Nam: Lic.No: APPLICATION / PERMIT C
BUILDING-ELECTRICAI.PLUMBING-hCHAMCAL CA RY CONTROL M
Architect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address 1'IXhITI55UANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION —
Ihereby
xtionaffirm that lam Bcensed 3 oftheesnessaonsof Cha pter9(e.and c APPHANCESRFSIDENI7AL JOB DF5CR0'TION
ingwlth Section fomear Dlvldon3.!rias Busimsaand Pro(eslonaCode,and my
Llamab4xi force and effect. PANELS
LI¢nse Chn LIGN
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
nt0 z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA ' $/SQ.FT.
OC
tj Llc.ns.d Professional SIGNSELECTRICAL
�6 OWNER-BUILDER DECLARATION SPECIALCItCU1T/M]SC
Ihereby affirm that l am exempt from the Contractors License Law forthe -
pp)Zfollowing reason(Section 70015,Business and Profesiom Code:My city or I:. TEMP.ME[ER OR POLE INS!.
c.untywhichructum requires.peorIssuance,
alsovctiresth,impmvgt for such permit
repair
rm any.sigrere price tostatement
its that
he,Is also and pursueat to the revisions of the ['OWER DEVICES-
d4 (Ile a signed statement that W b licensed pursuant to the proWlore of the •
i3u. Contractors License[aw(Clvpter9mmot
(coelngwith Section 7000).!Divi- SWIMMING POOL ELECTRIC VALUATION
rn
S
05 the lauHhor the alleged
Any violation
n of Sec execop 7031.5 by and
Op the War forth.alleged exemption. Any vtotacivi of Section 7031.5 by any OUTLETS-SWITCHES
applicant rod a permit subje<seheapplicam t.a civil penalty of fiat more than
five hundred
own Wr of
fthe pro NEWRESIDENTIALELECTR SQFT. STORIES TYPECON.'"IRUCTION
I,as owner.!theproperty,.rmy emture Isawithwage r their sole'k7Q compensation,Btsinest.rul kandthes Coule: bwontractor.t Intended Urff Law
5 D d for
dile(Sec. pply to alnowand property
Code:The Contractor.Hremn law
�S$ whododoes tsuch toan.wmrolproperty who bulmplds oyces,punted that
OCC.GROUP RES.UMTS
who ovementsare work tint a dee.roffered rough hisownemp,hrrwo provided that such C.
ROUP
Issoid titiindneyearfcompreale.theoweveptIcier the illhavding r - TOTAL:
improvement b sold within one ycaro(complctloM the owner-bulkier will have
rrden of pmving that he did not build or improve for purpose of.uk.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
p(I L as owner of the property,am exclusively contracting with licensed p pLSgUANCE
cont cion to mmtmd the project(Sec 7044,Business and Professions Code:
The Contractor's LI¢nx law don nut apply to a^.caner of property who ALTER-DRAIN 4[VFNI-WATER(FA)
Wilds m imp..thereon,and who mntracta fee such pd
lojes with a FEE SUMMARY
�gRffactorte)h¢nsed pursuant to the Contractor's License Law.. BAIX FLOW PROTECT.DEVICE
I_jI am exempt under Sec. B k P C for this reason
DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
fie - ` u Date RECEIPT
WORT 1 Ch PENS ION DECLARATION FTXTUI PERTRAP SCHOOL TAX Y_ N_
❑1 hereby affirm that 1 have a (Rate of consent m eet!-inaurc,ora I RECEIPT N
¢nifiateo/Wm]ura'Compersano m ran¢¢a¢rtifedc pythenrof(See. GAS-E .SE -I INCA PARKFEE Y N
RECEIPT
Policy N GAS F.A.SYSTEM-OVER 4IRA)
Cram any BUILDING DIVISION FEES
MConifled copy b herebyfurnished.to city GREASE/INDU L [ - O PLANCI-IE KFEE
❑Certified ropybfiled with the dry inspection division. _ PIP CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP f� PRIP
COMPENSATION INSURANCE j
RNssectionnnednotbee.mpleirelB<hepermitbfor.m hundred dollars SEWER-SANITARY- RM EA.200FT. I� [Ii1 I� '— Date Recti tq
(E1W)¢ImJ
WATER IffATER W/VENT/Q,ECTR ENERGY FY— N
I¢rtify that in the performanre olthew¢kfor which this permit is based,
I shall not employ any person in any manner so as to become subject to the j i I e:
Workein'Compensatlon Laws of California. Date WATI]t SYSTEM/TRIATI
z Z Applicant NEW RESIDENTIAL PLMB. SQS•T. Date Recel t#
Z ^ shouldNOTICTO esubje subject
orl,orfter aklomperationi,this Certificate of ExcmpteLyou
tl should become subject to the Workers'Compewtlon provisions.!rias Labor - TOTAL:
CC9 Code,you=at forthwith complywith such provisions orthis permit shall be - BUILDING FEE
jdeemed revoked.
W — CONSTRUCTION LENDING AGENCY - SEISMIC FEE e'a
tl (hereby afRrmtleat there Is a mrutmctlon lending agency for the perform ELECTRIC FEE
Z ..cc of the work for which this permit is lsurd(Sec.3097,CIv.Q TOTAL:
O O, Lender.Name PLUMBING FEE
F Lender's Andre.. QTY. MECHANICAL.PERMIT FEE
LLhatl MECHANICAL FEE
ion
O W I¢nt. tagreet c mplymaultwith
city and county
tordinances
abovedMatertlaws
-
U) Is rornct.Iagreel.mmplywBh andherebaordinancesand Mate this PERMIT LSSUANCE PEES PAID:
>. relatlngtobullding comwctlon,and hereby authorize representatives of this
N city to enterupon theabove-reentbnM property,for Inspection purposes. ALTER OR ADD TO MECH.
2 Date Rmciptit
V
(We)agree t.save,Indemnify an d keep h the City of Cupertino against liabilities.jadgmenb,costs and expenseses which may In any wayacaue AIR HANDLING DNIT CTO 10,000 CFM) I SUBTOTAL:
ag.Wtuld Cit In. eque a of the Ranting of this permit.
AIR HANDLING cmTr(OVER Ia,WBCFM) CONSTRUCTION TAX
�•c CONSTRUCTION TAX PAID:
Signature of AppBram/C.mract.r Date E%T7AU5'T HOOD M'/DUCT)
HAZA RDOUBMATER IALS LOSURE
Will the applicant or future building occupayf store or handle hadardous HEATINGUMT(TOIW,WBRRp Date Recei Ip
material as defined by the Cupertino Munlcil Code,Chapter 9.I7,and the
Health and Safety Code Section 2553I(a)7 HEATING UNIT(OVER I W,000 BTU) TOTAL:
❑Yn . MN.
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RERD) ISSUANCE DATE
which emit harardous air contaminants as defined bythe Bay Area Air - P
• Quality Management D❑isDistrict? IAS®
District? BOILER-COMPOHPOR1W,0W1TU) 1'1
P4 YesN ouN.
h read rhehua smaterials requirements.oder Chapter 6.95 of BOILER-COMP(OVE11I00,000BM)
theC iff..bHealth&Safety Code,Sediors25505,25533and25534. I Y` I" t4a IsIM�
understandthatifthe WildingdoeanolarrentlyhaveatenanLthalitbmy NEW RESIDENTIAL MECH. SQ.FT
responsibility to notify the occupant of the nqu tremens which most be met ,
prior to isseance of a Certificate of Occupancy. C Of cuom l.4."tl
Owner or aulhorired agent Date 'TOTAL: ISSUED BY:�1•TTIrL�YLU v/ �•/
•
OFFICE COPY