22870 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: f"1 I'1(� O
lAc 2 LQLv BuS 228
neve _ one:
_H%JPi '1i'S3—�Q j CITY OF CUPERTINO-BUILDING DIVISION `O_I,1
C do raw u&.Na: APPLICATION I PERMIT I LR
O BU[LDINGELECnUCAI PLUMBING.MECHANICAL CATEGORY
CONTROLM
MA Itea/Engineers Lk.Na:
� r' QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aHtrm that l am licensed under provisions of Chapter 9(commn APPLIANCESRESIDENTIAL JOB DESCRIPTION
Ingwith See on7000)ol Dlvisim3ofthe BuMmmand ProfesslonsCode,and my
off.ss cl.. L=e "cited
; y'G Z Q/ PANELS G E}y .(
UP TO 2DOAMPS
ARCHITECTS DECLARATION 201-IODO AMPS
q�q�uu eel Zp I understand my plans shallbe used m public records OVERIODOAMPS to `Q ETj REA' � $/SQ.FT-
Fi� Licensed Professional SICNSELECTRICAL r(\\ L C ■V' /�
�<<Q y OWNER-BUILDER DECLARATION SPECIALCBMCUIT/MGIC T E R
iu�l Ihereb afflrmthat l am exemptfrom the Contractor's License Law for the
ZoF following renon.(Sedlon 7RiIS,Businemand Profession Cade:Anycilyor /
K7 2� mentywhkh requires,permit to construct,alter,Improve,densoliskorrepalc TEMP.MEI ORPOLEINST. Q /
5 anystructure prlorto its issuance,also requirmtheapplic nt for such pemdtto POWER DEVICES
h .file a signed statement that he h licensed pursuant to the provisions of the
w� ContractorsLim.Law(Chapter 9(commenclog with Section 7000)of Divi- SWIMMING POOL ELECTRIC
r�Og slon3 ofthe Business and Profeminro Code)or that he Is exempt therefromaM VALUATION
6 the bash for the alleged exemption. Any violation of Section 7[01S by any, ' OUTLETSSWHCHISflXTURFS
applicant fore permit subjedsthe applicant to a civil penalty elect mom than
five hundred1, a.dollars(MI(N)). NEWRISIDENTIALELECTR SQFC. STORIES TYPE CONSTRUCTION
�n ❑I,as ownerof the property,or my employees Is with wages m theirs ole
Q,
compensation,0K wilBusio the ness
and Pr and the s Cdurehn Intendedontractor or offeredI..
does not
t apply to alnow owner
f property
Code.The Contractors Gesme law
R who clotapply work owner ofp rough who Wllds or mploympcavnted that such
OCC.GROUP RES.UMTS
soleadoeremseenothemlfor ledoroughhis own e.11,ho eer,the uildin or _
Improvement are not indneyear co mprmk,theetwevegtheerwill have TOTAL:
Improvement tsoldwilhlnoneyearafcompldlon,theowner-W Oderwill have
ttt,tiurden of proving that he did rot baud orlmprove for purposeofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u 1,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.70K Business anfess
d Professions Code:
The Contrad es License law don next apply to an owner of property who ALTER-DRAIN k VENT WATER MA)
d
ilds or Improves thereon,and who contracts for such pipjes with s FEE SUMMARY
cga4adone)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B k P C for this reason
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N_
[]f hereW affirm that I have o certificate maranc of&Donne to uBdnare,(S • ��.N
ceniflLab of ,ricers Compewtlmlruurance oracentiled copythereof(See. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polk lab CJ
CalryN RECDING DIVISION
'
Com - CAS EA.SYSITM-0VERd(FA) BUILDING DIVISION FEES
Centiled copyt hereby furnished. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
n Cenified copy h filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.IDOFT. Date Rec'el t#
(Thlssedion need net becompleted tithe permit t forone hundred dollars
($100)ml..) WATER HEATER w/vENr/F7.ECTR ENERGY FEE Y N
I mrtifythat In the perfomunecof the work forwhich this permit b haued,
I shall not employ any person in any manner so as to become wbjed to the WATER SYS'IT]N/TREATING
Worken'Compenmtlonlawsof Callfomh.Date PAID
icant
Z 0 NOTICETO APPLICANT.It,after making this Certificate of Exemption,you NEw RESIDENTIAL ELMS. SQFT. Date Reeel I#
should become subject to the Wmmrs''Compematlon provision fthe Labor - TOTAL:
N
Code,you=at forthwith comply with such provhlons ortht permit shall be BUILDING
W j deemed rev.kcd.
CONSTRUCTION LINDING AGENCY SEISMIC FEE
CL e Iherebyaffirm that there h aconatructlon lending agency forthe perform- ELECTRIC FEE
M Z ance ofthe workfor which this pe rmlthhsued(Sec.3097,CIv.C.) TOTAL:
02 lender'.Name PLUMBING FEE
F lendersAddren QTY. MECHANICAL PERMIT FEE
O W tcoIcedlfythatl have read thhappliotionand statethattheabovelnformatian MECHANICAL FEE
1 rre[.l agmato comply with all cityand muntyardlnances and Mate laws PERMTTL%UANCE FEES PAID:
>- W relatinglobullding corobuctlon,and herebyauthorlssrepremntativesolthis
f-. Z city to enter upon the above-mentioned property for Inspection purpome. ALTER OR ADD TO MECH. Date ReCel t#
— (We)agree to save,indemnifym
an d keep hadess the City of Cu pettino
against line.,pdgmenta,coMsand expenses which may in anywayacerue AIR HANDLING UNIT CIO,10,000 GEM) SUBTOTAL:
against 1 CityIn roes neso the granting of this permit.
U. ! AIR HANDLING UNIT(OVER 1BplocFM) CONSTRUCTION TAX
S' to fApplicsnt/ContractorDate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIII aapplicantorfulurebulldlegoccupant store or handle haaardcus HEATING UNIT(TO 10),000 BTU) Date Rocei t#
material a,defined by the Cupertino Municipal Code,Chapter 9.1Z and the
HealthYen No
(�""ltJnd Safety Code Sooner,25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Till the applicant orQwm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
wh lch emit havardous air contaminants as deEned by the Bay Area Air ��
Quality Management District? BOILER-COMP OHPOR 100,"BTU) D
4haveneed the h.2u,materials niaHeath&SafetyCode,Sed1..2550nbundeand2553r6.95of OLER-COMP(OVER 100,OWBTU) ( � )
the
erstaomh Health kildin Code,Sed1onsntly have
a tend,that 4.It
l+
reepostandlhat If the not
the cogdaes of not herrenllyhavaa tenant,that be
my NEW RESIDENTIAL MECH. SQ.FT. e7�'
rnpamibility to cena Certificate
of athe rcqulrement which rtwst be reset /l�
pdorm issuance ofa Cenlficate of Occopanry. �s( /sulk
na
Ownerorauthonmd agent Date - ISSUEDBY:
TOTAL:
OFFICE COPY