22054 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — U915 BALL POINT PEN ONLY
Building Project Identification PE MIT NO.
BseBd' lL%IrF� — 22054
a"��i�amaK6eta:aJ\� _ ars:
. �0 IeIS�`� CITY OF CUPERTINO-BUILDING DIVISION
Na ALL — EZ&TfZ c. Lie.No: APPLICATION I PERMIT
Arohlted/Engineer. y(- yp{y�� BIRLDINGELECTRICALPLUMBINC-MF NICAL CATEGORY CONTROL N
��ff''/y�� C—r°�" A " Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
AddrmD
d 5 i FT`t
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby aftlrm that l am licensed under provisions or Chapter 9(commeno- APPUANCFSRESIDENTIAL JOB DESCRITION
Ingwlth5edlon7000)ot Dividion3of Buainee and ProressionsCode,andmy
Bre n In spa dreg. ^� PANELS
Limn V L� Lie N
Date Contractor 4e
1TEC SDECLARATION MI-1000AMPS
q�q�vu O ..
on la e B be used as public records. OVER I ODO AMPS " SQ.FT.FLOOR AREA S/SQ.FT.
Fi U f) Ll V nee o SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIALCIRCUIT/M15C
Zp, Ihereby affirm that l amexempt from the Contractors Llmnm Law for the _
QQ QQ following reason.(Secilan70)15,Business and Profnxions Code:Any city or
�"i"'ty county which requiro a permit to construct,alter,Improve,demolish,or repair TIINP.METER ORPOLE INSI.
ISI 9 anyatm=mpriortoltsL ancealaorequimtheappgcantforauchper tto POWER DEVICES
go b file a signed statement that he Bernard pursuant to the provisions of the
3µ((-- Contractor's License LawK:hzpler9(mmmencingwith Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
X01 ei.n3.fth.Businemand ProfembmCWe).rthathebezempttherefromand
O.•57] the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETS-SWf.ICHRE FIXTURES
applicant fora permit subjects the applicant to a civil penalty of not morethan
five hundred dollars($500). $Q, STORIES TYPE CONSTRUCTION
�n ❑e sa owner of the property,or my employees with wages r there wk
NEW RESIDENTIAL ELECTR FT.
compec.70K Businothe ess and Professions Code;
he Contended oroffered for
D
sale(Secppy to an owandf pmFwuns Code:TM1eCimproves License Law
doe�B who notapply loan unser ofprough hisonemporees,prvidedtatand OCC.GROUP RES.WITS
EE whodoementssuch work am not
mseUwlhmugh hlsownemp,howevravldedilding h
improvement i.3old ithiIntended omyo roerect(arsaln,the er-bufldcrwdli v. TOTAL;
Improvement beaW within oneyeara(compldlon,theowner-bu0derwillluve '
UA.lionden of proving that he did not build or improve for purpose or sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed pp {yy ISSUANCE
mntrnctom to construct the pmjcd(Sec 70K Business and Pro(esslons Code:
The Contradm's License Lw son net apply to an.sonar of property who ALTER GRAN&VENT WATER(FLIT]
Solids or imp.thereon,and who mntram fee such p, b with a FEE SUMMARY
�+dw(n)Boomed!pursuant to the ContadoYe License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec B&P C for this reasonOUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEI'f'p
WORKMAN COMPENSATION DECLARATION Ftt�S,MR TRAP SCHOOL TAX Y N
QI hereby affirm orkemthat I have• amine of consent M dpytheure,ora RECEIPT N
3800,ab olWorken'Compewtlonlnsurana oraartifled copy lhercof(Sec. GAS EA.SYSTEM-1 NCA OUTLETS PARK FEE Y N
3500,lab 'e
Po11ry Y GAS EA.SYSTEM-OVER 4(PA) DINGRECELDT M
Cum +++sh BUILDING DIVISION FEES
•I Icentitled copy is hercbyteh d.
eGREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEEentitleded copy V Ned with
the city inspection division.
CERTIRCATEOP EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SE'WF.R-SANITARY-STORM EA 2MFT Date Rech i#
(Chia section need not be completed if the permit In(Drone hundred delta.
(g]00)rtifyt.) WATER HEATER W/VENT/FTLECTR ENERGY FEE Y N—
I
not that in any perhe son
to
any of mannehe workr
for to hich
pesubjecrmit is itoit.ssued, _
I shag not empty any person f any manner at as to become subject to the WATER SYSIEM/•TREATING
WorApplicant mpenutbnlawe of GBlomla. Date PAID
O Z NOTICE
NEW RESIDENTIAL PLMB. 9Q.FT. Date - Recei t#
ZO NOTICEco APPLICANT.If, orkefter rs'Comerationaking this lcateof Exemption,aLabu
should become sobfrd mthe Workers'Compensation provfelons of the Labor - TOTAL:
Ir N CodGyoumuetforthwithcomplywithsuchprovlalmuarthbper tl hallbe ,
W j 'deemed revoked.
BUILDING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform
t
7 Z Leer the work for whichper
not pedt biswed(Sec.3097,C1v.C.) TOTAL; ELECTRIC FEE-
02
EEUO lender.Name � � PLUMBING FEE
IL F Lender.Addrea QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O u 1wrifythat l have read lhbn
applicatloand natethattheabove Information
CL boomed.r agreeto complywithall cityand countyordlnances and date laws PERMIT ISSUANCE FEES PAID:
>- Cn relating to building construction,and hereby authorize represenlativm of this
F Z city to enter upon the above-cre.timad property for Inspection purposes. ALTERORADDTOMECH. Dais Recei i#
V _ (We)agree to save,Indemnify an p harmless the City of Cupertino
W45#
gmentx a whichmayinarywayamue AIR HANDLING UNIT(TO 10,030 CFM) SUBTOTAL:
i g of this permitAIR HANDLING INIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
ERIALSDISCLOSUREWill the applicantg occupant store or handle hazardous HEATINGUNIT(TO 100,0DO BTU) Date Re
t#
material as defined by the Cupertino Munldpai Code,Chapter 9.17,and the
fie Ithand SMcy,Code Sectton75537(a)? _ HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑yea' r��.I No
WilltheappllantwruWmbuilaingo pantuuequipmentordevicca VENTILATION FAN(SINGLE RFSID) 15SUANCE D011%
which archhnvrdous air contambromm ae defined by the Bay Arca At,
. Quality Management District? BOILER-COMP pFB'DR 100,000 BTU)
ta
Yrs ❑No
have read the hazardous.tedalarqui."nhunderCh.pter6.95of BOILER.COMP(OVER IW,000 BTU)
the GEfomla Health&Sa fety Code,Sect lona 25505,75533 and 75536, 1
understand that lfthe ify the ing doesoccupant of t errently equirt meatve a which
thatb met.my NEW RESIDENTIAL MECFI. SQ.FT.
responsibility of aCeheocate of of the requlrcmenb which muse be met
prior to issuance ola Certificate of Occupancy.
Owner or authorizN agent - Data i/Jf1�6
TOTAL: ISSUEDBY:
OFFICE COPY