22439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Add.;
111'« 22439
rhone6 / A
7 CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lie.No: APPLICATION I PERMIT "
.
ArchitM/Englneee Lk No: UIBLDING-ELBCTRICALPLIIMBING-MECHANTCAL CATEGORY CONTROL M
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
MU MILL"
Address: PERMITISSUANCE ❑ ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that lam Beensed under provisions of Chapter 9(exameeno APPUANCESRESIDENTIAL JOB DFSCROTION
Ingwlihsetlion in
7(00)ofDlvision3ofthe Businessand ProfessiansCodga dm
Ilam is In s forceti c.# PANELS a,IC
License Ct.r Uc
Date Coninear (
ARCHITECTS DECLARATION 2014000 AMPS
qM 2 I understand OVER 1000 AMPS SQ.Fr.FLOOR AREA /SQ.FT.
q��uu C my plain shall be used upublicrecoNe.
k o U Licensed Professional SIGNS ELECTRICAL A LD I N
<< OWNEReBUILDER DECLARATION 6T'FfIALCR(CUIT/MLSC sa A C
Thereby afRrm tOWKER-BLADE RDE DECLARATION
License Law for the 1\Y/t G +
po ppp (ollowing rtason.(SMlun 70315,Bucher and Pro(esslons Code:My city ass
Z^ county which requlresa permit to construct,Ater,improve,demoWh,orrepair TFMP'MEfERORPOLEINST.
IRq�0 7 anystmu mpKrtolblswamealsorequimtheappBrantfwr apermltto
S file a signed statement that he b Barad pursuant to the provisions of the POWER DEVICES
Q6 CuntncoeAUcnue Lew(Chapter9(commnncingwith Sett1on70W)ofDlvl-
�OS sion3 ofthe Business and Pofi.mCede)mthat bet.exempttherefmmand SWIMMING POOL ELECTRIC VALV
ess .T18
<Y the basis for the alleged exemption. Any violation of Section 7011S by any OITILETSSWITCHESFIXIVRFS
Applicant for a permit subjects theappflcant to a civil penalty of not rrore than
five hundred dollars($500). NEW RFSIDEN71ALELECTR SQ F1 STORIES TYPE CONSTRUCTION
®L as owner of the property,or my employees with wages as their sale
mmpensation,wBldotheworkandthestmc mt.rotIntended or offend for
Osale(Sec.7044,Businessand Professions Cade:The Contractor.License Iaw
$ does not apply to an owner of property who builds or Improves thereon,and OCC.GROUP RFS.UMTS
whodaeeuchworkhlmeelfa[hrough hlsownemployen,provided that such
Improvements are not Intended or offered for sale.14 however,the building or TOTAL:
Improvement bsold within oneyearofcompletron,the owner-bu elerwill have
t ben of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FTDODZDNE APN
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to constmet the project(Sec 7044,Business and Professions Code:
The Contractors License Law don eat apply to an owner of property who ALTER-DRAIN h VENT-WATER(EA)
Wilds or Improves thereon, and who contacts for such ptojetla with a FEE SUMMARY
ogR[(-ctaKe)lianeed pursuant to the Contna
ctb License L . BACK FLOW PROTECT.DEVICE
I am mmpt under See. B k P C for thh exon
Owns - — DRAIN&FLOOR ROOF,AREA,COND. SANITARY Y_ N_
• ORKMAN 42M P;&% ION DECLARA ON RECEIPT Y—
❑1 hereby affirm that I have a artif tate of conrnt to r161nsure,or a FDTNRE&PER TRAP SCHOOL TAX Y N
mAifiWeofWorken'Comper tlonlr ra moracertified ropythereof(Sec. RM=Y
38001L.abCJ GA&EA.SYSTEM-I MC.4OU11,= PARK FEE Y_ N—
Poli M RECETT If
GAS.PA.SYSTEM-0VER 4(FA) BUILDING
Com any BUILDING DI VISION FEES
ffCertified copy b hereby fumiehN. GREASE/INDUSIRLWASIEINTERCEPTOR PLANCHECK FEE -i
❑Certified copy is filed with the city lapection division. -
CERTIFICATE OF UEM"ION FROM WORKERS, GREASETRAP PAID
COMPENSATION INSURANCE SENT SANITARY EA 200FT Date RCcef I#
(Thlssecilon need not be completed if the permit leforme,hundred dollar
(S1I0)or lerJ WATER HEATER W/VENT/MFCTR ENERGYFEE Y N
I certify that in the perlormena e(the work(.,which this permit b issued,
I shag not employ any person In any manner An As to become subject to the WATER SYSTEM/TREATING
Workerd Compensation laws of California.Date - PAID
z Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei tin
Z Q N0110ETO APPLICANT:ILafter making this Certificate of Exemption,you
should become subjectlothe Wm1mm'Compemat1on provisioroofthe Labor TOTAL:
cc N Code,you=at forthwith comply with such provislos orthia .
permit shall be BUILDING t C
W j deemed revoked.
CONSTRUCTION is a ON LENDING AGENCY SEISMIC FEE ry
CL MO Therebyaffirm Mattheret.acoretisinuelending 097,agencyCiv.C.) perform ELECTRIC FEE
Z anoc of Lendee Nwork(or which this permit t.trued(sec.3097,Civ.C.) TOTAL:
LL O Le�sderYName PLUMBING FEE
lyf Lena era Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO lamtythatl have rend tht.eppllotionand siatethattheabove Information
dIs correct.l agreeto complywith all chyand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
relating tobullding coruuuction,and hereby authoriae rep.m.tives of thb
F Z city to enter upon the above�rnxtuoned Property for Inspection purposes. ALTERORADDTOMECH. Date Recei tq
(We)agree to save,Indemnify in d keep harmless the City of Cu ped Ino P
V
against liabilities,judgrants,costa and expenses which may In any way accrue AIR HANDLING[IMT DO IO,OW CFM) SUBTOTAL:
a est aid City In conaq�tnencs ofthe granting ofthbpenn . AIR HANDLING UNIT(OVER IO,ODOCrM) CONSTRUCTION TAX
. ( 'AM( CONSTRUCTION TAX PAID:
SIg.AdmAof AppBnnt/Contractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the appuant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Rtxei fin
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the -
Health and Safety Code SMion2S532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL: _
RYes rl��-I,No
ill the a ppllcant S2-ture building occupant use equipment or devices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit haaandous air contsmimnb as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHPOR 100,000 BID) PAR!\
('�1 Yes ❑No
%1R YY
47hZlead the havrdousmat'rials requirements under Chapter 6.95of BOILEILQOMP(OVER 100,000BN)
the Californt.Health A Safety Code,Sections 25505,25533 and 25534, I J�1 } !C 10121
understand that lfthebulldingdoeanotarrentlyhave atenan4tha ltt.my NEW RESIDENTIAL MUV SQ.FT
responsibility to notify the occupant of the requirements which most W met
prior to issuance of a Ceafilam of Ocmpa ncy. a
Owner or authorizada
Rent Date TOTAL: ISSUED BY:
OFFICE COPY