22669 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildn Project Identification .,. PERMIT NO.
Building Address: 22669
046o j3LAO-t Ga cu �fi-Q00 G`4: .S�IS6
mesa one: APPLICA 11ON hU HMI I I A
(pe �"«%.C. [�-' C+7AT CITY OF CUPERTINO-BUILDING DIVISION
c°no-adnr."ams: °: APPLICATION /PERMIT
rchitect/Engineer. Lk.N. BIIILDINGELECnUCA MUMBINGMECHAMCAL CATEGORY CO T
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address
❑ ❑
LICENSED CONTRACTOR'S DECLARATION PERWIITISSUANCE ❑
I hereby a..700(hat lam Bcensefth.Buprovisions ofChaptcr9(rommen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwe is in fun force and efeian3oflhe BuslnevandPro(evloneCode,and my
licenseLtoons is in toll(ora and effect. PANELS
Llanse Class Lk.p I'"R
Date Contmdor— —UP TO 2DOAMPq
ARCHITECTS DECLARATION 201-1WO AMPS
DCO I understand my plans shall be used as public records. - - OVERIOOOAMPS SQ.FT.FLOOR AREA S/SQ.Fr.
Licensed lsrote.lorul SIGNSELFCI7(IGL c3
621: OWNER-BUILDER DECLARATION � ��
ZF' a I herebyaffirmthatlam exempt from the Contractor's License Law for the SPECIALC
q following reason.(Section 7031.5,Business and Professions Code:An city r
O f"iy cmuntywhich requiesa permittomrutruct,alter,improve,demalleh,orrepalr 'TMP• ORPOI.E INS)
°'3 7 any structure prior to its issuance,also requires the applicant for such permit to
file a signed statement that he is licensed pursuant to the provisions of the POWER D
O k Com.m,e.License law(Chapter#(commencing with Section 7000)of Divi-
30 sion3 ofthe Business ondProesslonsCode)orthat he is exempt therefromand SWIMMING _C� - VALUATION
the basis for the alleged exemption. Any violation o!Section 7031.5 by any
0 / ^^/
p<A sore than
[TfL 7CHESFI
applicant for a permit subjects the applicant to a civil penalty of not %TURFS
�a five un s ed owner of
NEW RESIDENTIAL ELECTR SQFI'. STORIES V TYPECONSMUCTION
..�n pe as owner of the property,or my employees with wage as[herr sole
compensation,will do Business work and the ionstrocture V not intended or offered for
D sale(.Sec.apply
to Business and f property
Code:The Contractors License Law
$ does notapply roan owner offplf rough who Wilds primproves
ovidedthatsuh CCC.GROUP RES.UNITS
who does ntsach orkMmeededoroffe dfis oul.wn ILho en,prthebrthatsuch
improvementsarenot intendedprofferedtale.ILhoweveq[heerildingve TOTAL;
improvement ineold wlthinoneyear°tmmpleBon,theowner-bullderwlll have
or
t1gJZSrden of proving that he did not Wild orlmpmeforpurpmeofsale.). QTY. PLUMBING PERMIT FEE FLOOD 7DNE APN
u L as owner of the property,am exclusively contracting with licensed' PERMIT ISSUANCE
contractors,to to construct the project(Sec.70Business and Professions Code:
The C°ntradoes License Law does am apply to an owner of property who ALTER-DRAIN kVENT-WATER(EA)
Wilds or Improve•thereon,and who contracts fm such pto(ects with a
c
fnacter(a)licensed pursuant to the Co"tncter'e Llan.Law. - FEE SUMMARY
lJ I am exempt under Sec. B k P C for this reason RACK PLOW PROTECT.DEVICE
Owner DRAINS FLOOR ROOF,AREA,CON I. SANITARY Y N
Date RECEIPT p
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOLTAX Y— N_
❑I hereby affirorkern that I have S Insure to of consent to self-insure,ora RECEIPT X
certlfiab of Workers Compevatlon lriauranceora certified copythereo((Sec. GAS FA.SYSTEM-1 INC.4 OUTLETS PARK FEE Y— N
Polis380D,Lab CJ
Policy p - DING PI p
Co any GAS EA.SYSTEM-OVER4(EA) BUILDING DIVISION FEES
ECehified copy ls hereby with
the city
❑CertRied ropy b filed with tM city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR FLANCHECK FEE - -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP JG�iaaf G�qp •�'
5
COMPENSATION INSURANCE SEWERSANITARYSTORM EA 20OFI Date Recei t# w
AID a
(This section need not be completed BtM permit Vfor can hundred dollars -
(5100)orinv3 WATER HEATER W/VENT/M Ff,I.R E RGYFEE Y N
Icenotertify employat In the
onin nce
the so as tobcwhich envesubjrmit is Issued,the T^ rJ t( —
I shall not employ any person In any manner..to beams subject to the WATER SYSTEM/TREATING �/'�Ct /'
Workers Compen.tion Lsys of GBfmrnla. Date P D r0 /O
O Z NOTICApplicaE NEW RESIDENTIAL PLMIL SQ.Fr. Date Recei t#
Z O NOTICE TO AI'PLICANT:R,Aker making this Certificate o(Exemptbn,you
should become subject to the Workers Compensation prov6loe of the Labor TOTAL:
fD Code,you moat forthwith comply with such provide. rthis permit shall be BUILDN 'E
1 deemed revoked.
(L G CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Iherebyaffirm that them N a construction lending agency for the pedmrm TOTAL: ELECTRIC FEE
0 ance of the work(or which this permit is issued(Sec.3097,Civ.C.) ELECTRIC FEE
V Lender's Name
LL f Lender's Addm. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1cartifythatl haveread thisappBationand statethattheabove ln(omrsaim ',
CL Incorrect.Iagree t°complywith all city and county ordinances and elate laws PERMIT ISSUANCE V e' V' FEE AID:
N relatingto Wlldingcoetructlon,and hereby authorize representative ofthis i 1 4yr!J�
Z dty to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH, Date G—1 R2eei t#
— (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against Babilitle,judgments,mats and expenses which may in anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL: s
against said City in consequence of the granting of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signature of Applicant/Contractor Date EXHAUSTHOOD(W/DUCT) - CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappllant or future building occupant store or handle hazardous HEATING UNIT(TO 100,ODO BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,ChapterSIZ and the
[iEATING UMT
Health and Safety Code Section 25532(a)7 (OVER 100,000 BTN s TOTAL:
RYes M No
IB the applicant or future building ecapant use equipment or devices VFNIILATION FAN(SINGLE RESID) ISSUAN DATE
which emit harardous air contaminants as defined by the Bay Area Air �� !In
Quality Management District? BOMER-COMP 0HP OR 100,000 BTU)
Yes o No
have read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) -
theCalifornia Health k Safety Code,Sections 25505,25533 and 25534.1 „-,
understand that lithe building doe not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT �• Uf1M
responsibility to notify the occupant of the reqummxmts which must be met
prior to Issuance of a Certificate of Occupancy.' i
Owner or authorised agent DateISSUEDBY:
TOTAL;
OFFICE COPY