22688 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: _ 22688
caner a one:
�0 'T Wti 3 CITY OF CUPERTINO-BUILDING DIVISIONL—��
c°n a o'aNa Zj/ r� Ne APPLICATION I PERMIT
BUILDING-ELBCTRICALPLUMBING-MF LAICAL CATEGORY CONTROL#
'( Architect/Engl Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCIE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION -
Ihereleyaffirce that l am licensed under provisions of Chapter9(comment APPLIANCES-RESIDENTIAL JOB DFSCRR'TION
ingwith Se on7000)°fDhvblon3ofthe Businessand Profe.tonsCode,and my
L'..a 'Classin (yrg�an Ill.N (� r�y2 PANELS
Lianee Class=Ill.X' S ISJD J
Date Contractor —UP TO 20OAhTS
ARCHITECT'S DECLARATION 201-1000 AMPS "
µo!aO ZpC I understand my plans shall be used as public records OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
yU Licensed Professional . SIGNS ELECTRICAL ~•,T LED 1 N
Gfn 6 OWNER-BUILDER DECLARATION 1
�.., I herebyafRnnthat l am exempt from the Contractors License law for the
SPFLJAL CIRC[BT/MISC
po following reason.(Sealersrmitto o drum and Pmfessbns Code:Any city or y, )) �j P" TER -
�,Zf cmuntywhich rcqulresapermittocorutruc[,alter,impswe,denxelbh,ormpair TFMP'hfE7'ER OR POLE INST. `ai' /
�e4 anystructure priorw itsissuance,also requlreathe applIcantfor such permitto POWER DEVICES -
file a signed statement that he b licensed pursuant to the provisions of the
jaw Contractors License Law Chapter 9(mmmencing with Section 7000)of Dol-
Mon
ol- SWIMMING POOL ELECTRIC
VALUATI
H O Mon3 of the Business and Profe.lom Code)orthat he is exempt therefrom and
the basis for the alleged exemption. Any violation of Section 7031.5 by any 0[TTLET'SSWITCHESHXT[IItFS
applicant fora permit subjects the applicant to a civil penalty of not more than
o five hundredI,asoodollars(epro NEW RFSIDFNYIALELECTR SQ.FT. STORIES TYPE CONMUCTION
CCLCCC777777 ❑I,as owner of the property,or my employees with wages a thele dole
ldothe
C mm(Sec.lion,Business and Professions
Code:Thure Contractorect or License
Law
'S O
Is(Sec.apply
Business property Code:The Contractors Llceve Law
whadodoes tapchy rkhtan owner lorth=glywho
nempoyimproves idedthn,and OCC.GROUP RES.UMTS
cab rdmessuch workMmaelf intended tisroughhisownempbyes,providedtisatsuch
are
improvement
mprovement issold thinayear foreoplationered for the however, deerhe ill g orhaw TOTAL:
Imp rove an of proving that he did of comporImprove fee purpose of sakave
the kurden ower of the p M did"mound or Improve cenly feepurpose
lurnse QTY. PLUMBING PERMIT FEE FLOOD ZDNE APN
L-tr 4 as owner of the property,am.7044,exclusively Business
and
with I,Code:
contractors to construct the projetl(Sec.7014 Businem and Profoabna Code: � PERMIT ISSUANCE ,
The Contractors License Use does Am apply to an owner M property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improved thereon,and who contracts for such pipjects with a - FEE SUMMARY
riaetor(s)licensed pursuant he the Contractor's License Law. BACK FLOW PROTECT.DEVICE
I am exempt under Sec B &P C for this reason
OwnerDRAINS FLOOR,ROOF,AREA,CONE. SANITARY Y N
Dale REGRET'[X
WORKMAN COMPENSATION DECLARATION FD(IURES PER TRAP SCHOOL TAX Y N
❑1 hereby affirm that I have o Insurance
of consent to op thereof
ora REER4«
certificate oracertified copythemof(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARKFEE Y N
Polis Lab C.) ��P11 7
GAS FA.SYSTEhf-0VER4(EA)
Cony BUILDING DIVISION FEES
Certified copy b herebyth the city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ed
❑Certified copy b filed with the tlty inspection division. '
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRAP' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.20alrr, Date Recei t#
(This section need not be completed If the permit b for one hundred della.
($1 lesa.)
I omiWATER HEATER W/VENT/ELECTR ENERGYFEE' Y N
anlfythat M the performance o(thework forwhlch this permit lablued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California.Date PAID
.Q Z Applicant NEW RESIDENTIAL PIMB. SQYT. - Date Recet t#
Z O NOTICE co APPLICANT:to a cur ricers' iomper Certificate is oiempt ns of a Labor
Code,shoulyou=at
forth ithco Workers'such provisions
or this permit Labbe - - TOTAL:
LU N deemed revoked.
forthwith comply with such provbiov or this permit shall he BU
W 9 deemed revoked.
ILDING FEE
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE 3
I hereby eorkfor w there i a construction lending agency(erthe perform, ELECTRIC FEE
D Z ance of Lced.e Name for which this permitbbsued(Esc.3097,Civ.C.) TOTAL:
OO lenders Name � PLUMBING FEE
LL l— Lenders Address QTY. MECHANICAL PERMIT FEE ECHANICAL FEE
O O I mrtlfyihatl have readthis appllcatlonand statethatthe above Information
LU
bcorrect lcgreeto comply with a8 city county ordinances Blare laws PERMIT ISSUANCE EES PAID:
} relating lobulldingmrutruction,and hereby authotlze repreeemativeaefthls -- -
H 2 city to enter upon the above-mentioned property for bapectbn purposes. ALTER OR ADD MECH. Date Receipt#
_ (We)agree to mnity an d keep harmless the City of Cu pertme
:g a, ,pdg ,mstsand ea ch nay In anywa statue AIR HANDLING UNIT(TO 10,000 CFM) L SUBTOTAL:
agairut said h sequence ohne gr Ing ott Ia pennlL r AIR HANDLING IIMTCVER 10,000 CFM) CONSTRUCTION TAX
V /
Signatereof Applicant sates t EXHAUST HOOD(W/DUCT CONSTRUCTION TAX PAID:
H OUS MATERIALS DISCLO$UR
Will the applirf w5m building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date ecel t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Hen
alt Yend Safety Cod e,SeNiice 75532(a)t HEATING UNIT(OVER 100,000 BTI. y� TOTAL: Kew
-
o
Will the applicant or❑future building occupant use equipment or devices' VENTILATION FAN(SINGLE READ) ISOJ c SATE
which emit hazardous air contaminants..defined by the Bay Area Air
Quality Management District? - BOILER-COMP OHP OR 100,000 BTU)
Yea mNo a�4haysPudmaterials requirements underChapter6.95of �
_
BOILER-COMP
the California Health&Safety Code,Sections 25505,25533 and 25534. I
- understand that if the building does not currently have a tenant that it is my NEWRESIDENTIALMEIN. SQ.Fr.
responsibility to notify the occupant of the requirements which most he met
prior to issuance of a Certificate of Occupancy.
Owner or authorlad agent - Date ,. ISSUED
TOTAL:
OFFICE COPY