22306 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMH NO.
Building Addreva:
I0t12) 6 v 22306
weer. acre: ^ �
��sj L� L Moral CITY OF CUPERTIN6BUILDING DIVISION /
Connctue. me: Lie.No: APPLICATION / PERMIT l`�
BUILDING-ELECTRICAI.PLUMBING-MECHANICAL CATEGORY CONTROL N
� ArcFlted/Englyder. Lk.No:
QTY ELECTRICPERM/T FEE BUILDING PERMIT INFO
Addrsss
PFRhBTI55UANCE ❑ El ❑ .
LICENSED CONTRACTOR'S DECLARATION
IMreection70that iamnsim3 fkheunder BuirouWd mChapterodeand c- APPLIANCESRESIDENTfAL JOB DESCRIPTION
in ease i Semon force and effeon3ofthe BuslydsaandPro(esslonsCode,and my
Li
license lelnfuu fora and t.N - PANELS
License Clam LIC.N
Date Cormador —UP TO 2DOAM5
AACHITECPS DECLARATION 201-I000AMN
ppre'Z I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
p�00
L1 ..If Profeaebnal - _ SIGNS ELECTRICALA L E D f
<6LI.n't OWNER-BUILDER DECLARATION SPECIALCEtCUIT/MLSC
71.,-7� Iherebyaf@mthat lam31.5,B from the d Professio Llmme Law for the Iia n � r'
qqqq following reason.(Section 70715,Bu and and Professions Code:Any city or '\Y C
K u( countywhkh requlmapemmitto comxnmci,alter,renprovq dennWh,orrepalr TEMP.METER OR POLE INST.
3 anyrtrudureprimt.1tsiawance,a lacrequimstheapplicamforsuchpermluo
S POWER DEVICES o�
L5 floe a signed statement that lu b r9(co d pursuant it the pon700) of the
3k� Comredor'a License LewrofessimuCdurencing with xeroptth000)of Dldl- SWIMMING POOL ELECTRIC VALUATION
SOS tlon3 oflhegusNess and ProfemloroCode)orthat hebexemptthem(romand .
0 the basis for the alleged exemption. Any violation of Section 70715 by any OUTLETSSWITCHESFIXTURES
applicant fora permit subjects theapplicant too civil penalty of not mom than
five hundred dollars(5500!.
�n ❑I,as owner of the roe NEW RESIDENTIAL ELECTRSQ.FT. STORIES TYPE CONSTRUCTION
property,sty,or he employees with wages r/here rule
a, compensation,Budoewill theworkandlhe rtrode:TheCure is mmercintendedorcense Law
O dale(Sec. pply 70K to anower (property Co builds or Improves
License iad
who ddoes oes
apply tomownel ofpropertyhis
wn em lcyn wvided thereon,and
�^ whodoesauchworkhbruelforthwgh hieownemployees,provided that such OCC.GROIIIr RFS UNITS
Improvements are not Intended oroffered forsile.If,however,thebulldingor - TOTAL
Improdemcnt bmld withinone)earofcompldioktheowner-buRderwBlhave
tl(Upujycnaf proving that he did notbulld or improve furpurposeofsele.). QTY, PLUMBING PERMIT FEE
�y—pL,tae owner of the property,am exclusively contracting with licensed F7.000 ZONE APN
morn an to construct the project(Sm 7066,Business and Professions Cade: PERMITISSUANCE
The Contradoeo License law does not apply to an owner of property who ALTER-DRAIN kVENT-WATER(EN
builds or Improves thereon,and who contracts for such ptojecis with a FEE SUMMARY
cgmpdor(s)Rcenmd pursuanttothe Contractor's Linen Law. BACK FLOW PROTECT.DEVICE
El I am exempt under Sec w
B k P C for this rean
Owner Date DRAINS FLOOR ROOF,AREA COND. SANITARY Y_ N_
RECER'T N
WORKMAN COMPENSATION DECLARATIONSCHOOL TAX Y_ N
affirm, FIXTURES,PER TRAP
❑I hereby affithat I have•certificate of consent to selMmure,or a RECEIPT N
certificate of Workers'Comperdation Imumnm ma orrtBkd copy thereof(See. GAS EA.SYSTEM-I INCA OUTLETS PARKFEE Y N
- M00,lab C.)
Policy N RECEIPT N
GAS EA.SYSTEM-OVER 4(EA)
Com any BUILDING DIVISION FEES
Certified� copy b herebyte
❑C.nlfled copy h(firs withh the
city
e sly inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP. PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20OPT. Date Recei t# .
(This section need not be completed If the permit Is forore hundred dollars
($10(fiorlen') I WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I mnlfy that In the performance of the work forwhlch this permit is Issued,
I shall not employ any person In any manner co as to brooms subject to the WATER SYSTEM/TREATING
Workeme Compensation Laws of CaldomU. Date PAID
C Z Appllcant - NEW RESIDENTIAL PLMB. SOFT. Date Rece1 tN
Z O NOTICE TO APPUCANT:If,after making thisCertiicate of Exemption,you
should become subject to the Workers'Compensation pnwidurd of the Labor TOTAL:
N Code,you at forthwith comply with such provisions orthb perrnbhall be BUILDING
W deemed mooed.
FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
1 I herebyaffinn,that there la a conetmdlon lending agency for the perform- ELECTRIC FEE
Z ance of the work for which this permit is l ued(Em.3097,CIv.C.) TOTAL:
O O Iender.Name PLUMBING FEE
F Lend.e.Addre.a QTY. MECHANICAL PERMIT FEE
LL MECHANICAL FEE
O W Irsdllythatl.Ii,grctocouplywitppliutynand dcunty ordinances eInformation
IL bmnrect.Iagreeto complywln all ndhembyouhmim pmd,ctnd date lam PERMIT ISSUANCE FEES PAID:
} relatingoenterupont mmbe-mandndherebyrtyorinrepresentatives slfhb -
z d (We)
ree to sae,Indemnify ned
keep harntl Inspection purposes. ALTER OR ADDTO MECH. Date Recei tM
(We)agree to jade,Indemnify an d keep harmless the I.a of Cupertino
r .gams r.sldCity judgments, and expenan which mayln anyway scone AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agaimd Id City in consequen ftM granting of this permit
AIR HANDLING UNIT(OVER IO,OW CFM) CONSTRUCTION TAX
`g reof Applicant/ radon - Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MA ERIALS DISCLOSURE
Will thea limn or future building occv nt store or handle hazardous HEATING UNIT(TD 100,000 BTU)
material as definedPby the Cupertino Municipal Code,Chapter 911 and the _ Date RCcel ttl
Health and Safety Core SemFIEAT WG UNIT(OVER 100,000 BTUT on 25533(a)7 TOTAL:
❑Yea 0 No
Will the applicant a,future building occupant use equipment ar devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air comaminantsas defined bythe Bay Area Air
Quality Management District?No BOILER-COMP pIE'DR 100,000 BTU)
Yea ❑No
have read the haeardoua materials requirements under Chapter 6.95 of BOR.ER'CAMP(OV!?i 100,0110 BTU)
the California Health A Safety Code,Sections 25505,25533 and 25536.1
understand that if the building does not currently have a tenant,that It is my NEW RFADENTIAL MECL SQ.FT.
responsibility to notlly the occupant of the reyuhuments which must be met 4/
prior to issuance of a Certificate ofOavpanry, ale'
Owneror authodeed agent Date ISS
e a r r D
' TOTAL:
OFFICE COPY