22685 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project IdentificationPERMITNO.
Bwlabgadd 2— t3 6 Id /('ds4-e-- 22685
nes. a .I one:
tl CITY OF CUPERTINO-BUILDING DIVISION
°^ �• : Na. APPLICATION I PERMIT
BUILDING.ELECnUCALPLUMBINC MECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address:
PERhRTISSUANCE 1SCI. ❑ ❑ ❑
Lby en that ED CONTRACTOR'S DECLARATION �J7
I hereedionmlhatlamsim3afhunder BuMnonslmeo(Cssions9(mmmrn AI'PIdANCESRESIDENTIAL JOB DESCRIPTION
Ingwith in fou
and my
limns le In fu8 died. PANELS
LIcen�Lk.M v
Date Contractor S,
ARCHITECT'S DECLARATION x11-1000 AMP"'
p❑+NO Zp I understand my plans shall be used u public records. OVERI=AMPS N'`Q. AR�� S/SQ.FT'
E00 Licensed Professional SIGNSELECTRICAL LED
z� y OWNERexNPDER DECLARATION SPECIALCIRCUIT/MISC �" T E R
eZyy Ihereb a(Rrm Bullam exempt fmmthe Contractor's LlmNel�w/m the
op following reason.(Sedi.e 7031.5,Business and Professions Code:My city or
OZo TFMP.ME[ER OR POLE INST.
�� .aysimhmpriulresapermitmmnsrequ alttheaprovgderrsuch,er tto
q any awcturetatementahat he he alsomrylrosuant tthe fmsuiom,of to POWER DEVICES MND
ilk a dgned statement that he b Bmnscd pursuant toted proaMlons of the
0631.,Iy. Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC �
F�OJ slon3 alias Business and PrefeslonsCode)orlhat he is exempttherefromand VALUATIO
the begs!orthe alleged exemption. Any violation of Section 7031S by any OUTLETSSSWITCHE&FIX TURES ,1
applicant fare permit subjedstheapplicanl to a civil penalty of nal mare than (f
five hundred dollars($.500), NEW RESIDENTIAL ELFLTR
E]1,as owner of the Property,or my employees with wages as their sok `"Q'FT. STORIES TYPECONSTRUCTION
C compensation,will d o the work and the structure Is not Intended or offered for
0 -1.(Sec.7044,Bu.mose and Prolesslmu Code:The Contractors License Law
$ does not apply to an ownerof property who bulldsorimprovesthereon,and
^ who doessuch work himself orthraugh his awn emplWeu,provided that each OCC.GROUP BE.UNITS
improvements arc not Intended or offered lar sale.It,however,the building or TOTAL;
Improvement tosold within am yearofcompldlon,the owner-builderwlll have
tlR,purdon of pmving that he did seat build or Improve for purpose of uk.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
Lj
I,e.toner tr the property,am exclusively Business
ess andPe with licensed Code: PERMIT ISSUANCE
11c Contractor's
to mnslmd the project,not apply
Business and Professions Code:
The ,orimpo es then Taw don rad apply tom owner of Property who ALTER-DRAIN&VENT-WATER(EA)
buRda or Improves thereon,and who contracts for such pVojeda with a FEE SUMMARY
c tad m' exempt
rat under ec.rothe Conmactora Lirenu Law. BACK FLOW PROTECT.DEVICE
LJ I am eaempl under Sec B&P C for this reason
zEES
DRAINS Y FLOOR ROOF,AREA,GOND. SANITARY Y_ N�
Owner Dare RECI797 N
WORKMAN COMPENSATION DECLARATION FIXTURFS PER TRAP SCHOOL TAX Y N
Q hereby affirm that I have o Insurance
nsures c of consent to copy
ythereo ora RECmrf.9
38MflL bCj orkers'Compensationlnsunnreora certified mpythemo((Sec. GAS F.V.SYSEEM.1 INC4 OUIL67S PARK FEE Y N
3800,Lab CJ REC=X
Policy N 9�-- GAS EA.SYSTEM-OVER 4(EA)
Cam any � BUILDING DIVISION FT:ES
E3elfffifCertlfl copy and copy b(Bed with the city herebytumcity inspection division. P.RCGREASEANDUSIRL WASTE INTEPTOR PLANCHECKFEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE7RAP PAID
COMPENSATION INSURANCE - SEWER-SANITARY-STORMEA.x18FI'. DRIC ReceI tN
(Thi,mation need net be completed lithe permit b foram hundred dollars
($100)wlc.) WATER .�W,/vFNT/M TR ENERGYFEE Y N
I mrtlfy that in the pedornanre of the work forwhlch this permit le beaed,
I shall Am employ any person in any manner so as to became subject to the WATER SYSTEM/17TATIN'G
Workers'Compensaffon laws of Callfomb.Date PAID
OZ Applicant NEWRESIDENTIALPLMB. SQYT. Date Recei tg
Z O NOTICE TO APPLICANT.If,after making this Certlfkafe of Exemption,you
should become subject to the Warken'Compensation provbions of the Labor TOTAL:
CCN Code,you=atforthwith comply with such provbians or this primus shall be U ••E
W > deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d I hereby affirm that there bammtru4on kndingagenry forthe perfoms TOTAL: ELECTRIC FEE
O ante oft1mwmk farwhichthb permit hi issued(Sec.3097,Clv.C.)
Tenders Name PLUMBING FEE
U. Lc.derb Address QTY.1 MECHANICAL PERMIT FEE MECHANICAL FEE
OW Imrtilythatl have readthb applicationand slatethattheabove Information
6 bmrecd.Iagree to complywilh all ordinances and county ordinana and Kate laws PERMIT ISSUANCE FEES PAID:
W relating to building construction,and hereby authotoe mprowntatives of this
F city to enferupon above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Z (We)agree t ve,Inv=an d keep harmless the City of Cupertino Date Reeei til
V m
agaltliabllil ,judgmemI mebre
..d e.prma.which may In any wayarue AIR HANDLING UNIT 8010,000 CFM) SUBTOTAL:
age not u Ity•In mnsequ 9fThe granting of M.permit.
MR HANDLING UNIT(OVER I0,000CFM) CONSTRUCTION TAX
Sigmtureaf Applicant/ mtradur Da EXHAUST HOOD(N/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCIASU E
Willtheappil. or(ufure but gomupant.tore or handle harardous HEATING UMT(TO 100,000 BTU) Date Recei ted
material as definer the Cu Municipal Co do Chapter9.1Z.mithe
HealthaM Safety Code n25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yen o
Will lhezpplimnt ar turebullding.pantmeequipmentardevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit laardous air mato nnas defined by the Bay Area Air
. Quality Management Dbtri BOILER-COMP DHP OR 100,000 BTU)
Yn o
haveread Health
mets cootertab requirements 2555,2553 aChapter.1 of BOILER-COMP(OVER 100,000 BTI)) Ams
the California Health&safety,Code,Sections currently
h 25533 and 25539.I
understand that lithe theobuilding don outmmrequirmnts whichf,that itbmy NEW RESIDENTIAL MECH. SQlrf v
responsibility to asRty to of a Certificate
occupant of the requirements which must be met !:
prior to luuanre o(a Certificate of Occupancy. � q
Owner or authimaed agent Date TOTAL: ISSUED BY: /
OFFICE COPY