22663 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address:
503E G L/FDEN w GUf �T/uv c� 95a1S� 22663
unT� one:
_D4 9 K U -F—u- /Ci CITY OF CUPERTINO-BUILDING DIVISION /R I^ _�y
Contractor's Name: un. APPLICATION 1 PERMIT '�) K. '-L
L� l.tJ (Ai Dal ' BUILDINGELECnUCALPLUMBING-MECHAMCAL CATEGORY CONTROL
Archetact/Fngincer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. I'FRhRT ISSUANCE s[�' � X
LICENSED CONTRACTOR'S DECLARATION - �J
I hereby affirm that l am Bcensad under provisions of Chapter 9(commem, APPIJANCESRESIDENTIAL JOB DESCRIPTION
Ingwlth Section 7")o(DIv1Yon3ofthe BuYnemand PmfeW onsCodeand my
license is in full fora and affect. PANELS
License Clam LLCM
Date Contractor UP TO 2DOAMI-b
ARCHITECT'S DECLARATION 101-1000 AMPS a
p❑❑p+±9Z • lundentandmyplamshaBbeusedmpubhcrecordw �r OVER 1000 AMPS SQ"'`IT.FLOQRAREA 5/�.FT.
Q
t UL1®'QtFo
E do� Licensed Professional - - f'P ry
<fn If OWNER-BUILDER DECLARATIONSI'EC'41L
ZF,H Iherebyafflmnthat l smexempt franthe CamractorbLiana law forthe W -
po (allowing reamn.(Section 70315,Business and Professions Code:My city or
O 2
, t
-
TEMP.METER hkh sp p h,orre
anystmureriortoibWanealsorequiurCheahmntformchpetto0 Roe a signed statement that hb licensed pursuant to the prom of
O Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi64SWdMING I(OL FlECIINRSIC�'uF
VALUATION
O the bleb for the alleged exemption. Any violation of Section 70315 by any OUTLETS&WITCHESFIXfURESL 2� 8e'7 tot Q�
app0an ra pemdtsubjedatheapplicmttoa civil penalty.fnot morethan l
I{� fie red dollen($500).
,as owner of the property,or my employees with wages as their sole NEW RISIDFNTIAL ELECTR �.FT. STORIES TYPE CONSTRUCTION
compensation,will do the work and the structure b not W ended or offered for
I �O sak(Sec 704y BwNese and Profembm Code:The Contnctor'e Lirenu law
B does not apply to an owner of property who WIS.builds or improves thereon,and OCC.CROUP RUMTS
who doessuchwoM
rkmmBarthmugh M..wn employees,provided thatmch
improvements are not intended oro(fered fasale.It however,thebullding or TOTAL:
Improvement haoldwithinoneyearofcompletlon,theowner-buBderwdl have
ftkurden of proving that he did notbuild orlmproveforpurpaaeofsaoe.). QTY. PLUMBING PERMIT FEB
LJ L as owner of the property,am exclusively contracting with licensed ar,�t FLOOD ZONE APN
The Contractor's
profM(Sec.7M4,Business and Profession Code: PERMIT ISSUANCE W
The Contnctor'e License law don net apply to an owner of property who ALTER-DRAIN k VENT-WATER TA) (�
Wilds or Improves thereon,and who contra for such projects with a
FEE SUMMARY
cgR¢acror(s)Baneed punuanlrothe Cantactori Llama Law: BACK FLOWPROEECT.DEVICE
Lj 1 am eo t n Sec. B&P 9 for this mason SANITARY Y N_
OUTSIDE FEES
Own.u Date DRAINS FLOOR ROOF,AREA,COND. RECEIPT.#
VOR(IHAN1 OMPFNSATION DECLARATION t/'� SCHOOLTAX Y_ N_
❑I hereby•(firm t6a I have a artl0am of consent to self-Insure,or a FIXTURES.PER T r t Lw
RFGF7 f M
rertlflab of Workers'Compewtlanlmunna ora artlfled ropy therm((Sec. GAS EA.SYSTEM-1 MC4 OUTLETS PARKFEE Y N
Polic lab CJ RECEIPT I
C. I GAS EA.SYS11A1.OVER 4(EA)
Com any .BUILDING DIVISION FEES
[Certified copy is hereby famished. GREASE/INDUSIRL WASE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' I GREASE TRAP PAID ��
COMPENSATION INSURANCE SEWER-SAMTARY-STORM EA 1(IOFT Date . t#stt—Id t�
(Thlsseelloo need not be completed If the permit bfor one hundred dollars
($100)or less.) WATER HEATER W/VENT/E.ECTR ENERGYF N
I artUythat N the performance.(the work forwNch this permit is bared,
I ball not employ any person In any manner n m to became subject to the WATER SYSTEM/TREATING
Workers'Campematloa Lawsof Caltfamta.Date PAID S-0
O Z Applicant NEW RESIDENTIAL PLMB. SQFf. Date Re I t# w
Z O NOTICE TO APPLICANT.Itafter making the.Certificate of Exemption,you
should become subject to the Workers'C.mpemation provisions of the Labor TOT
I'm N Code,you must forthwith comply with such provisions orthb permit shall be BUILDING
j dermed revoked.
W — CONSTRUCTION LENDING AGENCYart��r SEISMIC FEE .00
a Z Ihereby affirm Hut there b a comtmetion kndingagency,forthe perform TOTAL `art'1 ELECTRIC FEE
lam of the work for which this permit b bared(Sec.3097,Civ.CJ a-e/
V O lender's Name - PLUMBING FEE Qq
I= Lender's Address - QTY. MECHANICAL PERMIT FEE
W MECHANICAL FEE
OLU _#mer. thatl Ianato comply withaBatynand dcutyordiheces and gate laws
LU
bmingt building comply withal] hereby
authorise
representatives
and gate awe I'EiMITLSSUANCE, {„) FEES PAID:
_} N rely to enter
Wlldingmmuuctxottondpropauthorize represenpurpos ofthis
cit to entero on the property for W Ion purposes. l ALTER OR ADD7C)MECH. (�
I_ Z y P P pPhar pe1Y P Kuper Date Rece t#
(We)agree to rove,Indemnify an d.rep harmless the City of yway.pert ins,
V agalm abll roti nn,
and npensn which may In anywayamue AIR IiANDWNC IJNTf(TO 10,000 CFM) SUBTO AL: '
a ansa It c p�uens oft his t.
y / /�el AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatureo(AppOa / ord d., Date i EXHAUST HOOD(W/DUCD CONSTRUCTION TAX ID:
HA 1 DOLS MATERIALS DI SCLOSURE
Will the applicant orfulure building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTI)) Date Recei
pk
material as defined by the Cupertino Municipal Code,Chapter 911,and the
Hcalthand Safety Cede Sectlon1S531(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: t
❑Yes No
Will the a ppliant or sure building occupant use equipment In devices VENTILATION FAN(SINGLE RESID) IS ATE
which emit hazardous air contaminants as defined by the Bay Area Air -
Quality Management District?o BO[LER.COMP OHI'OR IW.000 BTIl)
q Yes ❑
Ihave read the h.,d smaterials requirements under Chapter 6.95 of BOILER-CDMP(OVER 10,000 BTU) 111 s'u ���•
the California Health k Safety Code,Sectiom 25505,75533 and 15534.I p aa{p �a�, As
understand that if the building does not currently have a tenant,that It b my NEW RESIDENTIAL MECN. SQ.FT 4�ty,YL VII�WMRW
responsibility to notify the occupant of the requirements which mut be met 41`r' V Gaff
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED
TOTAL:
OFFICE COPY