22798 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address:
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(:;:- lL_ CITY OF CUPERTINO-BUILDING DIVISION S �^
ntradnr.N me: Lic g APPLICATION I PERMIT Lb L =T ti/D g BUR.DINGELECTRiCALMEPLUMBINC HANICAL CATEGORY !-HROL 0
Architect/Engirreer.
Lk.N.N.o:
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l sen licensed under prwWons ofChapter9(mancome. APPLIANCFSRESIDENTIAL
ISedi°n tn3ofthegudnemandProlnslonsCedeend my
JOB DE9CRB7ION
It...1s In forcesendflec. PANELS �� 9
License Clams N sass
Date Contractor
ARCHITECPS DECLARATION 101-1000 AMT'S
❑❑p±±Oreo I understand my plam.hall be used as publicrecords. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
E Liconsed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION B ALE N
IJn SPFGIALCIRCUIT/MISC
IherebyaffirmthatIamnampt froBusiness
d Preanols License law fort he
following reason.iresa o7037$Budnem and Pimpro%,, Code:hocity it
O� t~� POWERMETERVICES POLE INST. O
� carntywhkh rcqulrnaperndtroeotuteud,alter, demalbh,or repair
any structureprbrroIts hat heIssuance,Is alsolice sed ires the pusuant t thepfor isions permit o PO4VER DEVICES
1 4 Co a signed statement that he is r I(cons pursuant to I&,provisions of the
Contrador'e Licerue Law(Chapter 9(commencing with Sedlon 7000)of Divi- A
IliI"n SWfhTMING POOL ELECTRIC
g (he beds
Burmese ed Professions AnyArthath of exempt therefrom and �'�'. A
S^ the basks for the alleged exemption. Any tolacivi of Section 70315 a any
65
applicant lots permit wbjedsthe appOcant toadvll penityofnd mare than W OUTLETSSWITCHESflXCURES
five hundreddollarsthepr. NEW RESIDENTIAL ELF= SQ.FT. STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employees with wages r their woe
7 a .1.elecompenc.
will doSuture the work,and rudureh eCHnlendedo Licensd for
e I..O role(Sec. pply to an owner
df property
Code:The uilds or improves
sUcoeon Law
�$ does doeot s
such torn owwr olpropertywho nemporlmproovided thereon,and OCC.GROUP RFS UNITS
who doement.aarkhimself dedoroughed owns.If,howeprwWedthatsuch
Improvementsareweintended arofred Tarsalst(h er-q Elder illn or 70T
ImprovemcnHswW wllhinoneyearolcompldkReheowner-W Rderwlll have
tt .Ilurden of proving that he didnot build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
U 4 as owner of the property,am exclusively contracting with Ikense! fl.00D?ANE APN
contractors to mmtmd the project(Sm 7044 Business and Professions Code: PERMITISSUANCE
The Contractors License Law does not apply to an owner of property who ALTER-DRAW&VFM IS a
-WATER(EN
W
builds or Improves thereon, and who contra for such Inplacts with a FEE SUMMARY
contractor(s)Emoted pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sec B&P C for this reason
OUTS I DF FEES
Owner Dao
DRAINS FLOOR,ROOF,AREA,NND. SANITARY Y N
RpGm•T p
WORKMAN COMPENSATION DECLARATION pD(TURES-PERTRAP BOOL TAX Y_ N_
❑1 hereby affirm that 1 have a artle®te of consent to self-Inarc,ora RFGEIP T N
certificate of Workers'Compensation Insurance or a certified copy thereo((Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y N
BBw,Izbc3 ._/ 9999.5-7�
TX
Co env n'�I$L<rF�RI./ /anJA/ ia�G'� IC /tO GAS EA,SYSTEM-OVER 4(EA) BUILDINGDING DIVISION FEE
sencopyV hereby(urnlehed. �' t a PLANCHECK FEE
❑Certified copy b filed with the city Impaction division. GREASE/NDUSIRL WASTE INTERCEPTOR
CERTIFICATE OF F3(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-570RM EA 100F1' Date Recti t(t
TThbsedion need not becompided if ted permit Is forom hundred dollars
($10Morlem.) WATER HATER W/VENT/ELECTR ENERGY FEE Y N
I mnifythat In the performanreof the work lorwhich this pemut to Wiled,
I shall net employ any person in any manner an as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z . Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you
should become aubjed to the Workers'Compensation provisions of the Labor TOTAL:
CCN Code,you muat(orthwith comply with such provisions or this perrNt shall be B D
W
> domed revoked.
CL G INC FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Iherebyaffirm lhatthere is a conteurion lendingagency forthe perform ELECTRIC FEE
3 Z anceoflheworkfor whichthb permit 6 busted(See.3097,CIv.C.) IOTA :
02 Lenders Name PLUMBING FEE
IL 1— Lenders Address QTY. MECHANICAL PERMIT FEEMECHANICAL FEE
OW Icertllythatl have read this appBcetionand state that theaboveinfomvtlon
1 is correct.Izgreeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating to building corutroction,and herebyauthorlae representatives ofthb
F city l°enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
Z Date Recei ted
— (We)agree to cove,Inde Hy`m d keep harmless the m a y Cupertino P
egalretllabNtie dgme coateand expenses which may roanyway casae AIR HANDLING UNIT RO 10,000 CFM) SUBTOTAL:
t id �si�n sen r==une gran ting cdude emdt�/ AIR HANDLING UNIT(OVER Ia000 CFM) CONSTRUCTION TAX
Signature of Appllanvc°n�� ,/s// Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,00)BTU) Date Recei IN
material as defined by the Cupertino Municipal Code,Chapter 93Z and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL.jk 09
❑ Yenr No
Willtheapplkant oqw.Wildingoaupantuwequlpmentmdevkcs VENTILATION FAN(SINGLE RLSW) ISSUANCE DATE
which emit hazardous air contaminants as defined by the gay Area Air
.
Quality Management District? BOILER-COMP OTE'OR 100,0(10 BTU AID
Yea I❑''�No MM
Thavemad the hanrd Non teriabrequirementsunderChapter6.95of BOILER-COMP(OVER 100,000BTTn
the California Health&Sa fety Code,Sections 25505,25537 and 25534.1 SEP
understand that if the building does not mmently have a tenant,that It is my NEW RESIDENT)AL MECH. SQ.FT.
responsibility to n0 By the ocmpact of the requirement•which at be met -
prior to Issuance of a Cer iflate of Occupa nry. ft
�Nof rNUm1f1n9
Owner or authorized agent Data TOTAL: ISSUEDBY: e `� '
OFFICE COPY