22069 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Praea Identification PERMIT NO.
Building Address:
( O Silo - 22069
p oJZk�.
reuI Name - - one:
�V CITY OF CUPERTINO-BUILDING DIVISION
°ntrartnraName: Lie.No: APPLICATION / PERMIT l
BUILDING-ELECTWCAGMUMBING-MWC LAICAL CATEGORY CONTROL#
Architect/Engine.,. Lie.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE (Z.GYJ51,13(a hI.LLI PLUMB M�n
❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ection70 that leml:c¢sedhelhaless.rd provisions of Chapter 9(commen APPLIANCES-RESIDENTIAL JOB DESCRB'TION
In coax i.atfon7000)ot Divfelon3ofthe9uslnessand ProlessionsCode,and rcy
Ilcenes le In(ul fo, deflect, PANES
13 Lit
Date Contrator_�ay�
ARCHITECTS DECLARATION 201'1000 AMI"'
pSQ.IT. AREA f/SQ.FT.
p��++ail ZO (understand nn)'plaes shall be used as putt c recorcis. _ 1
Licensed Professional SIGNSELECTRICAL
<<< OWNER-BUILDER DECLARATION
InSPECIAL CIRCUIT/MISC
7p, [hereby a(firmtlut lam exempt from the Contractor's License Law for the
fo0owing reason.(Section 7811.5,Business and Professions Code Any dtyor
Fcounty which requires a permit to construct alter,improve,demolish,ornpalr TEMP.METER OR['OLE MSI.
`'0 a arty structure prlorto its lawaree,also requimthe applicant for such permit to POWER DEVICES
Hct
a shed statement that he is licensed pursuant to the provisions of the
Contractor's Lice.Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC ' VALUATION
Oa sion3 of theThminess and Pmfenloru Code)orthet he is exempt therefeemaM qq��
G•] the bash for the alleged exemption. Any violation of Section 78)1.5 by any 3 OUTLETSSWITCHESFIXTURES '"2.0 061..D t 0 d
O
applicant for a permit subjects the applicant to a civil penalty of not more than
RF. 1,as ed owner of the pr. NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPE CONSTRUCTION
❑I,as owner of the property,or my employess with wages r thele door
compensation,will B..doth.workend toes Code:The
at intended o iofferedfor
O sae(Sec.apply
to anow andf property
Code:The or Improves thereon law
3 F$ does not apply to an owner of property who n builds or Improves thereon,and OCC.GROUP RES UNITS
who does
ments am work
nothimself
tended rough Msow or ale.It owev provided
,thebthat such or 1t
Improvementaared withiodedarrofc pldiomthe neer-builderwdingoe TOTAL: �J
Improvement hsold withinoneyearo(completion,the owner-bullderwlllisave
t rden of pmvlog that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
j1,all owner of the property,am exclusively contracting with licensed
comnnton to comtmet the project(See 70K Bualneen and Professions Code: PERMITISSUANCE
The Contractor's License,law does not apply to an owner of property who ALM-DRAIN&VENT-WATER(FiU
Wilde or Improves thereon,and who contract.for such pmjets with a FEE SUMMARY
cgR[(actor(a)licensed pursuant tothe Cont etor'e Lt...Law. BACK FLOW PROTECT.DEVICF.
LI T me exempt under Sec B k P C for thin reason
OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
RFOEB'T Y
WORKMAN COMPENSATION DECLARATION IiXTl1RFS PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that I have a mKificate of consent to self-Insure,or
¢rt10¢te of Worke W Compevatfonlrsunn¢ora¢rtRhd copythereof(Sec. RECENT Y
'00,Lab C.) GAS IA.SYSTE14-1 INCA OUTLETS PARK FEE RECI]PTY
PolicyY CAS EA.SYSTEM-OVRR 4IRA)
CBUILDING DI Vi SION FEES
Ned copy is hereby fumiahed. GREASE/INDUSfRL WASTE INTERCEPTOR PLANCHECK FEE
Willed copy is filed with the city Inspection division.
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.WIFE DBte RCCCI IN
(This section need nu W completed If the permit is forone hundred dollars
($100)or less.) WATER HEATER W/VENT/E.TLTR ENERCYFEE Y N
I¢rtlfy that N the performance of thework forwhlch this permit I.issued,
1 shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RESIDENTIALMMB. QFT. Date Re i tic
Z O NOTICETO APPLICANT:H,afterraki.g this Certificate of Exemption,you
H should be ecomsutt
bjeco the Workers'Compensation provisions of the Labor TOTAL:
F_ N Codgym=stforthwlthmmplywlthsuchprovhioaorthhpermitshalibe U
W j deemed revoked.
CONSTRUCTION LENDING AGENCY' SEISMIC FEE
a I herebyaffirmthat then h a construction lending agency for the perform TOTAL: ELECTRIC FEE
0 arm oftheworkforwhlch thispemet he Issued l5m.W17,Clv.C.)
[enders No. PLUMBING FEE
LL H Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icedlty thml have read this application and statethsttbabove Information
C iscorret.Iagreetocomply with aRcity and county ordinances and state Ia. PERMITISSIJANCE FEES PAID:
N relating to Wilding comtmctlon,and hereby authorize representatives of this
F.. U) city to enter u Pon the above-mentioned property for inspection pu rposes. ALTER ORADDTO MECH. Date ReceJ [#
_ (We)agree to save,Indemnify an d keep bareness the City of Cu pertlm
aga Inst liabilities,Pdgments,.9.and expense.which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against Bald Cltyl s,,LL of the gr ing of this permit. AIR HANDLING UNIT(OVER 10,(X0CFM) CONSTRUCTION TAX
Signature of Applicant/Contra Datv EXHAUST HOOD(W/DUCTS CONSTRUCTION TAX PAID:
HAZARDOUVMATERIALS DISCLOSURE
Will the applicant or feturebullding occupant atmeor handle haaardms HEATING UNIT CIO 100,000 RI1n Date Recd tic
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cmlg lealon255321all HEATING UNIT(OVER 100,000 BTU) TOTAL' L
Rill
l Yes 'pplica. . rMNo .
Ilenut applicant.. core Wilding occupantuseby therefulpmentBay Area devices VENTILATION FAN(SINGLE RES[UI I$ 4 6DATE
which emit hazamd....ir contaminants ad defined by the Bay Area Air — 'W/
Quality Management i 9� BOILER-COMP OFN OR 100,00D BTU)
4Y¢ ����J��JQQ��fJ'�o Q
hawe read the hafardgue materlah requirements under Chapter 5.95 of BOILER-COMP(OVI]i 100,000 BTU) pR per �
the Celifemla Health h SafetyCode,Sections 25505,25533 and 2:534. I
understand that if the Wilding don not currently have a tenant,that it h my NEW RESIDENTIAL MECH. SQ.FT.
respoestbBlty,to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate of Occupancy. ���—/�s�
Owner or authorized agent Data ISSIIEDBY:.V V�IIJ
TOTAL:
OFFICE COPY