22446 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PER ITNO.
Building Address:
a od, L 22446
wnereone.a - q
me CITY OF CUPERTINO-BUILDING DIVISION —
c° CP4
Jry7APPLICATION I PERMIT
P"'s/Q/1�itr7" Ns" a oaS/ BUILDING-nECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL
A tte)ct/'EnIgineer. LIc.Nu
yk lV ��6 dl BUILDINGPERMIT INFO
QTY ELECTRIC PERMIT FEE
Address:/6Oy' s q�`GyP/e �[ / r PERMIT ISSUANCE I Z Nr El ❑
LICENSED CONTRACTOR'S DECLARATION
thereby
ofIlan that l am licensed under provisions ofChapterg(comment, APPLIANCFBRESIDENIIAL JOB RIFTION
Ingwith Sedion7ODO)of DIW.Ion3ofthe B..I.eoand ProfeasionsCode,and my
license la In(u end d(M. p PANELS
LIcen�Lic
UP TO 2DO AMPS
Date Con[ndor 70110)OAMI'S
ARCHITECT`S DECLARATION
�qqP!!00 Zp Iunderahnd my pore stall be used opublic records. OVER 1000 AMPS SQ.ET.FLOOR AREA f/SQ.Fi.
E Licensed Professional 9GNSELECTRICAL LED I N
GG Q tfi OWNER-BUILDER DECLARATION .
W
SPECIAL CIRCUIT/MISC
Z t., [hereby afOrmthatlam exempt tram the Contractor's License Law for the
lo0owing reason.(Section
KO E�Kt F 7011.5,,Business and Profeoloa Code:Any city or
[EMP.METEOR
[OLE INS[.hkh requ4cea pvempmveh,errepalr
anydrucurc ptlorto Its Istuanceasomquirentheapplicant forsuch pemNtto POWER DEVICES
P T E R
e
a signed statement that he Is licensed pursuant to the provisions of the
Dµ Contractor's License Law(Chapter 9(comemocingwith SeHon70W)ofDivi.
Oe' SWfh1A9NCPOOLFlECIRIC TE
elon3 of the Businesacnd Floteolons Code)arthrt he h emmpt therefromarW TION
6 the basis for the alleged exemption. Any violation of Section 7MIS by any OUTLE7SSWITCHESFIXTURES
applicant fora permit objects the applicant to a civil penalty of not more than
five hundred dollars($SM. NEW RESIDENTIAL ELECTR SQPr. STORIES 'TYPECONSIRUCTION
❑L as owner of the property,or my employees with wages as their sole
compensatlon,will dothe work,andthe structure bi not intended or offered for
O sale(Sec.7046,Business and Pm(esbn Code:The Contradot.Llceme Law
does not apply to an owner of property who builds or Improves thereon,and OCG GROUIa RES.UNITS
who does such work himself or through his own employees,provided that such
Improvements are not intended oraffered for We.If,however,the building or TOTAL: a
ImprovementissoidwlthlnoneycarofcompletloNtheowner-buflderwill have
elgkurden of proving that he did not build or Improve for purpose of sok.). M. PLUMBING PERMIT FEE
L, FLOOD ZONE APN
L as owner of the property,am exclusively Business
ess anding wtth licensed PERMIT ISSUANCE
The Co to to construct thew doeit not apply
Buslneo an, of property
Code:
The Coor improves
License law don rad apply tc an owner d property who ALTER-DRAIN k VENT-WATER(EA)
huBda or Improve thereon,and who comrade for such pRajeda with• FEE SUMMARY
cTTIcto ..cmptt under Srt m
the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am ezempt under Sea B k P C for this reason
Owner Data
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPENSATION DECLARATION RECEIVE=FDnIJRFS.PER TRAP SCHOOL TAX Y N
❑I hereby.them that I have•certificate of consent to copy
Chemo ora RECEIPT
N
3800,Lase ofWorkere'Compensdlonlnsunnce oraceHfkd ropythereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y_ N
Polis Lab
PoligN ,; c ^99 39� /6'//If GAS G.SYSTEM-OVER4(EA) BUILDING
Com any BUILDING DI VISION FEES
led copy is hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE��-r
PIC"effled copy b filed with the city Inspection division. _ �] y 7/
CERTIFICATE OF UEMPTION FROM WORKERS GREASE TRAP PAID/�6"LA Lt-2
COMPENSATION INSURANCE
(Thlsscdlon need not be completed if the permit is(Drone hundred dollars SEWER-SAMTARY-STORM EA.7001[. Date Re i t
(f100)mleo3 WATERFIFATFRW/VENT/ELECTR ENERCYFEE Y
I cemlythat in the performance of the work forwhich this permit is loved,
I shall not employ any person In any manner se as to become subject to the WATER SY57EM/TREATING
Workers'Compensation Laws of California.Date PAID
-
Z
Z Applicant NEW RESIDENTIAL PLMB. SQ.ST. Date R tt'i til
NOTICETOAPPLICt tothe, ort maklomng I a cation Certificate oft the
should become subject to the Workers'Cempersatlon provisions o(the Lebon T AL:
CC N Code,you most fan hwith comply with ouch provisions or this permit shall be U G
j deemed revoked.
FEE
W — CONSTRUCTION LENDING AGENCY - SEISMIC FEE L
CL Ihembyafflrm thatthereba construction lending agency for the perform- TOTAL: ELECTRIC FEE a
O ance of the workfor which thls=t is Issued(Sec,.3097,CI,.C.)
Lender's Name PLUMBING FEE
LLF Lendee.Addreo QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW ieco1certify that l have mad this application and state that the above lnaormatted
W rrod.IagreetocomplywRhallcityand countyardlnancesand date laws PERMIT ISSUANCE FEES PAID:
>. 0.W relating to building construction,and hereby authortm representatives of this
(_ to enter upon the ovnmmbInspection property for pection purpose. ALTER ORADD70 MECH.
city ab
z (We)a to save,Indemnify i n d keep hareNeo the City of Cupertino Date R t#
V sit atto }rad meco penoav
whl mayinanywayecce AIR HANDLING UNIT(TO 10,000 CFM) SUBTO AL:
ago told i of anring 1 rmlt� ! AIR HANDLING UNIT(OVER 10,010CFM) CONSTRUCTION TAX -
7
Signature,of Appllant/Contractor Date EXHAUST HOOD(W/DTIC]) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futore building oceupant store or handle havardous HEATING UNIT(TO 100,ODO BTU) Date Rece Ile
material as dell tied by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25537(a)) HEATING UNIT(OVER 100,W0 BTU) TOT O
4Ye. M No
111 the applicant°r(stun,bcilding occupant use equipment or devices VENTILATION PAN(SINGLE RFSID) �.a NCE DATE
which¢colt havm7ousair conta niments as defined by the Bay Area Air r
Ilty Management District? BOILER-COMP OTD'OR 100,OM BTU)
. Yea n❑us PI
a have read the haeaedom materials m Irerrenh under Cha er 6.95 0( BOILER-COMP(OVER 100,000 BTU)
heCaliforniato Health ASldin Code,Sections25505,21511hveatand,that. 1
he California tlathe AL Safety
don nor vrrentlyh,21511 nant,t511ltVmy NEW RESIDENTIAL MECH. SQ.FT.
ompomibllity to notify the occupant of the requirements which must be and yry Ii/�aaasnedl�'
prior to Lou,race M a Certificate of Occupa Ary. JWL�^YIlI�-'�A,{ ��
Owner or auihoriied agent Data ISSUED'Y;J16 � WV' -�L/
TOTAL:
OFFICE COPY /