22318 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Buildln Pro'ect ldemification
BWld Ing Address: PERMITNO.
4 - 22318
Phone: .
CITY OP CUPERTIN0.6UILDING DIVISION
°"'m` Lite No: APPLICATION /PERMIT
A (tett Cngineer BUILDINGELFCTRICALPLUMBING-MEGIiANICAL CATEGORY C NTROL p
Lt.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add reu . 2Imm—i Rim
-- 1'F3ihLTISSUANCE ❑ ❑ ❑
LICENSED.CONTRACTOR'S DECLARATION '
Thereby
affirm that l am Bcensed under Provhionsof Chapter 9(i,ornmene. APPLIANCESRESIDENTIAL
ingwlth Se iOn7000)o(DiAMon3ofthe Busimaand ProfealansCode,andmy IOD DESCRIPTION
Item se In h (r9�and dfeet. PANS
Limnn Contra
it
oop �7
Dale Contrar
ARCHITECT SD E,puce TION 701-1000 AMPS
Oa 7. I understand my phru eMB M used n pubBc records, OVER 1000 AMPS
�Q SQ.FT.FLOOR AREA $/SQ.FT.
<Z{IG37; Licensed Pm(emiorul SIGNS ELECTRICAL
�< OWNER-BUILDER DECLARATION
Ihembyaffimthatlamexempt(romthe Contmetor'sLlrense Lawforthe SPECIALCIRCUIT/MISC
Z qqqqqq following reason.(Section 7031.5,Ruslnen and Pro(ess7ons Code:Any city or
P4 muntywhichrequtr aPermitmmruttud,alter,lmp.v,demolah,ormpatr TEMP.METER OR POLE INST.
anystm tum prior tons issuance,also requiresthe applicantfar such permit to
rN1 file a signed statement that he Is limned pursuant to the provbiom of the ROWER DEVICES 7flZ i 5
30G Contractor'sLiceme Law(Chapter 9(commencing with Section 7000)of Divi-
GS slon3ofthe Buslnn.and Profemlarm Code)orthathelsexemptthemfromand SWIMMING POOL CTRIC VALUATION
5 the lasts for the alleged exemption. Any violation of Section 7W i.5 by any ^
O appllontInto permit subjects the applicant to a civil penalty d out momtha 1TILETSSITTCHES-FIXTURES a.l
five hundred dollen(S.500).
Z 1,as owner of the Property,or my employees with wages as their sole `W RESIDENTIAL ELECIR__SQ}T. STORIES TYPE—CONSTRUCTION
< mmpensatlon,wllldothe work,and theetrotturebna intended or offend for
❑
sale(Sec.7094,Business and Pro(essiom Code:The Cont.clol.Llatue Law
$ docs not apply to an owner d pmperty who builds or Improves thereon,and s�
whodoasuchwork Moelforthrough hlsownemployees,provided that such OCC.GROUP RES.UNITS
Improvements arc not Intended oroffered forsele.IL hmveveq thebulldlog or
improvementlssoldwithinoneyearofcompld3ogtMo ner-bullderwlll Mve TOTAL:
tl)„kumort of proving that he did not build or Improve forpurpoe ofsale.). QTY, PLUMBING PERMIT FEE
L_j S as owner of the property,am exclusively contracting with licensedFLOODZONE p-1N
contractors to coraWd the pm)ed(Sec.7064,Busmen ami Profesem.Code: PERMIT ISSUANCE
The Cmunsou is License Iaw don nor apply to an owner of Property who
Wqpiill1ddT.or Improves thereon, and who contracts for such pTjem with'a ALTER-DRAIN&VENT-WATER(EA)
el.JI am°e exempt underant Sm
the Contractor'sLlanse Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
pt ° B &P C for this rcawn
• OwnerDate DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y N
WORR IANCOMPDVSATIONDECLARATION RECEIPT#
O/hereby ef(Irm that 1 have a cenuflate of consent to°elf-Insure,or FIK'IUREfi.PER TRAP SCIIOOLTAK Y N
artlflate of Worken'Compematlon Irouranm ora attlfled copy thereof(Sec. RECEIPT N
ff
3800,Tab CJ GAS FA.SYSI'FM-1 INC.60UTLETS PARKFEE Y_ N
Policy#
Com Y GAS FA.SYSTEM-OVER 4(PA) RECENT M
erti0ed copy b hereby fumished. BUILDING DIVISION FEES
C3 Certified copy is filed with the city inspection division. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF E3(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Ttdssecthmered out becompldediftMpermt bmi.nahundred dollars SEWER-SANITARY-STORM E.A.200Fr. Date ReCei t#
(5100)our lea.)
Irertifythat N the Performance ofthe wok for which this pemdt is issued, WATER I RATER W/VEN/ELECTR ENERGY FEE Y N
I shell not employ any person in any manner n.to become aub)M to the —
O Workers'Compensationlawsof Callfamla. Date WATER SYSTEM/TREATING
Applicant PAID
Z Z NOTICE TO APPLICANT:B,after making tNs CertBia(e of&emption,you NEW RESIDENTIAL PLMB._SOFT. Date RC'CCI f#
Hshould become subject to the Workers''Compensation provisions ofthe Labor
NCade,you must fort hwilh comply with such provisions or this pvAnb shall be TOTAL:
W > dermed rev°ked. BUIL12ING
FEE
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
I hereby afBnn that there is a mtm
ractlon lending agency for the perform-
ane ofthe work for which this permit is issued(Sec.3097,Ch.CO TOTAL: ELECTRIC FEE L
V O I<ndee.Name
LL ~ Lender.Address QTY. MECHANICAL PERMIT FEE PLUMBING FEE
O W a
Irtitylhatl Mvc readthbappgationaM sate thallheaboveinf, tion MECHANICAL FEE
0. Nommet.I agree to comply withalldtyandmuntyordinancesandstatelaws PERMITISSUANCE FEES PAID:
)- N relaangtobuilding cormtrottlon,and hereby authorfu reprcxmativesofthls
F z city to enter upon lM above-mentiorsd property for ptattoo purpoaes. ALTERORADDTOMECH.
V — (We)agree to demnity and keep har me Ctry of Cupertino Date Receipt#
against llabli ,)a ts,costsandexpenses chtraylnanywayaatue AIR HANDLING UNIT 10,000CFM)
.9.1 ai co sena oftM gnntin ihla permit. $UBTOTAG
AIR FTANDL[NG UNIT(OVER t0,000CIM) CONSTRUCTION TAX
S nam of pliant/ o tntto Dat �Q EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ZA
HARDOUS MATERIALS DISCLOSURE ,/j
Will the applicant or(Aure building occupant store or handle H rd s HEATING UNIT(TO 100,000 BFUI
materialasdefiried by theCupertino Municipal Code,Chapter 9.IZ andthe Date Recei t#
bSafe
h and tyC EBTU).75532(.)7 HIATING UNIT(OVER IWAY)BT
(❑""I YC9 ° TOTAL:
TVllltheapplia r rmmre bultiing occupant use equipment or devices VENTILATION FAN(SINGLE RESID) I$$UApLCE DATE
which emit harardous It contaminants as defined by the Bay Area Air 1�
Quality Mawgement 1st BOILER-COMPOHPOR10Q000BTU)
4 Yes
have read osis o r)a In.25505,
2553 Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) U�
the orn Heall Sof ode, i'mntlyl veatand75536. I y �
I enters to if lyt d of eDequir hzvea tenant that It met NEW RESIDENTIAL MECH. Ay1sa}�
Q.F. h
I p rs m Ify t o p e requlmmenb which must be met
r Ce 1 to p racy.
or alit n 1Date
TOTAL: ISSUED BY
OFFICE COPY