22623 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-Building Project identification PERMITN
ification O.
OuIlJing�d3 � -c K�Ay �� 22623
nen amore: . 1 one. p
.g GE.va 2 CITY OFCUPERTINO-BUILDING DIVISION �— -� �-_ Cr I
Cono-a oyf9Ngme: Lm.No: APPLICATION / PERMIT lS C
I LAIC-�
-761"7z- BUfLDING-.ECTWCALMUMBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.No
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I'EI4MITISSUANCE ❑ ❑ �l
LICENSED CONTRACTOR'S DECLARATION
I hereby affirmthatIs.lken3ofthe usiiw Land Pmf hsion Codmrom anenc- APPIIANCESRES[DCNTIAL JOB DESCIUI'770N
Ingwlth t.full7000)of DlWelan3o(1he BuAnessandProteaelonaCode,and my
Licari le In cos fWce and s(.#. -a PANES
L at. lasrf ec T-, 711 LIcY
Date�7�f�7^/�4/1�Contractor UP TO 2XI ANTS
201 IOW ANTI'S ( 1. _{•/
ARCHITECT'S DECLARATION
pQ+OaO (understand myplamshagbeused aspublicrecords. OVERIODOAMPS SQ.Fr.FLOORAREA S/SQ.Fr.
E�
Licensed Pal SIGNS ELECTRICAL LED i N
«<<z OWNER-BUILDER DECLARATION �� /�
fn]3 SPECIAL CItCU[T/MISC P ,Kl
7,1-'Yd owing;ya -.5,allame1.5,Bumm/he Contraessio Lkeme Lawforthe
following reason.(Section 7mit t.Business and,lmpmona Code:My.p lr
F � countywhkh requbna issuar a,mrutequires the
eaprovndemplbhormit to TEINP.METER OR POLE INST.. 9 i]
any stsunedstaure menr to tshat M 1,licca requires to he provisionor such s
of the D sa,Y' 4� {y(
P� � fila a signed statement that he b licensed pursuant la the pmWlona o! the EWER DEVICES Y/A� V
O63µ Contmdoes Licer Uw(Chapter9(mmmentl gwlthSMlon7000)ofDtA-
O�^ Aon3o(the BusInm.dProf.ss .Cade)orthehelaenmptherefmmand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHES-FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not more than
five hundred dollars%W.
I,as owner of the m NEW RESIDENTIAL ELECTRSQ.Fr. STORIES TYPE CONSTRUCTION
�n ❑ property,or my emplayece with wages r their role
C compensation,wllldothe work
roand ions Cc
e:Tlana Intended orcense L w
5 q .1.(Sec.apply
to alnow andf property
Code:The or improvesors herem Law
v,h.ddoes os..chloanownerotpmpeth hi.meamptyeas,povided that
ryand
uch OCC.GROIIP RES.UNITS
whodpemotsaorkhimsen edorough hisowdle.It oweprovidedthatsuch
Impmvement+arenotintendedprofferedfplee thea vep gofer ilI have TOTAL:
Improvement la wld within oneyearofcompletbR th<owner-buBderwill have
"(den of proving that he did not build or improve for purpose ofsale3. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
11 L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
mntrsctors to construct the project(Soe 70K Business and Pmf daksa Code:
The Contractor's Llcerae Law dm not apply to an owner of property who ALTER-DRAIN k VENT (EA)
builds or Improves M - -
Megan, and who contracts for such pAojects with a FEE SUMMARY
contractor(s)licensed pursuant to the Contractors License Law. BAIX PLOW PROTECT,DEVICE
0I am creme War Sec B h o
P C for this mon
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,ODND. SANITARY Y N_
Owner Date RECEIPT N
WORIOMANCOMPENSATIONDECIARATIONFIX.Il7RES PER TRA]' SCHOOL TAX Y_ N_
�/ ❑1 hereby affirm Chet I have a certificate o!concent to self-Insure,ora
zJ mhitimteofWorker'Comperemonlruuranmoracertakdmpythereof(Sec. RECEIPT N b Isis C GAS FA, INC40UILL75 PARK FEE Y N
33mRECEIPT N
�.al Oj$�D�/S7 GASEA.SYSTEM-OVER4(EA)
Co.Cany „-] rC. /IAM7 fiL4- BUILDING DIVISION FEES
;Certlfiedcapyls �e�rcby(urnlahed. - GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORMEA.200FT. Date Re I tN
(This section need not be completed if the Permit la for one hundred dollars
($]M)erlm.) WATER FTEATFR W/VENT/m TR
ENERGY FEE Y N
I mmifythat In the performance at the work for which this permit is lasued,
.T Stull not employ any person In any manner m u to become subject to the
' Workera'Compeneation Laws of California. ATER SYSTEM/TREATING
.Date PAID
OZ Applicant NEIN RESIDENTIALPLMB. QFf. Date Recel tR
Z O NOTICETO APPLICANT:If,after makingthb Cerficamof Exempkn,you
should become subpect to the Workers''Compesuatlon provisions of the Labor TOTAL:
cid Code,yeumustforthwlthcomplywllhmchprovklomorthlapermitshallbe BU
W 7 deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
IL12ING FEE
Il lherebya(fim,Budtherefs construction lording agency(cribs perform ELECTRIC FEE
3 Z anceofthe work which thlapermit is lasued(Sm.3097,Civ.C3 TOTAL:
02 Lender's Name PLUMBING FEE
LL I- Leadrea Address QTY. MECHANICAL PERMIT FEEMECHANICAL FEE .A�
O W ce
I rtily that l have mad this application and nate that the above Information
1 Iscorrect.I agree to comply with all city and county ordleanms and Asia laws PERMIT ISSUANCE ,(JD FEES PAID:
�• relating lob mtmction,and hereby authorise expremnmtivee of this
N city to en opo eabove-menti pmperty(orwpemm�purpome. ALTERORADDTOMECH.
Z Date Recei t#
E3 flue) gree uve rr= d kcep harmless the City of Cupertino
ega WellabiJ a,Nd n n �penen which rtuy In any way+mue AIR HANDLING IIMT(TD ID,ODO CFM) SUBTOTAL:
agaWteal i In ( granting of this per It.
AIR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTION TAX
2J' 911
Signature fAppEcent/Cpntracto Date FJ(HAUS'r HOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appliant or future building occupant store or handle hausdous HEATING UNIT(T0100,m)O BTU) Ito k- —7-—1j q Date ReceI HI
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Fkalth and Safety Coda Section 25532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yea No
Willihaappilontor turebuilding occupant use equlpnent or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hasardous air contaminants as defined by tFe Bay Area Air PAM,Gustily Management District? BOILER-COMP QHP OR 100,DM BTU) M,
Yea ❑No
Tuve madthehaurdousmuleriaLsmquimmnbundcrChapter6.95of BOTLER-CDMP(OVIR IOg00D BTIA
the California Health A Safety Code,Section 25505,25533 and 2:534.1 f`UG pW 6 �7ys!Gp
understand that it the building docanot currently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT
ras�oraibBRy to rally the occupy rat of the requkempnts which must be met
prior to Issuance a a CeAificete of Omrpa racy.
r�•Owner orauthoriad agent TOTAL:Date ISSUED BY:_` Q
OFFICE COPY