22212 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification �� PERMHNO.
Building Address:
1 07c90 A-3. pf3."Zl)- 13wo, ��1� _ 2221.2
Ovvsae one: ,
>� s CITY OF CUPERTINO-BUILDING DIVISION 311
c°^o-a N me: Lk.N°: APPLICATION I PERMIT
BUILDING-ELF TRICAI PLUMBINGMECHAMCAL CATEGORYCONIZn I
ArchltM/ r. Llc No: b0
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrem PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION �/1J
I hereby affirm that l am licensed under;neximes of Chapter 9(cmumenc, APPLIANCESRESIDENTIAlIng JOB DESCRIPTION
llmnsth in full
7000)of force
effilon3oftheguslneaeand Pro(esslonaCode,and my � �`
license Is Ins !orae and ie.at
PANELSLicera ` 1
Date Clam Cont
Date Con[nctor UP TO 2DO AMPS
ARCHITECT'S DECLARATION 301-1000AMPS
Po±M Zp I understand my plana shall be used as public records. OVERIODOAMPS fjba SQ.FT.FLOOR AR���E---���Aaaa WSSQ.FT.
E� Licensed Professional SIGNS ELECTRICAL 14(�'/ Qa / y��
4446.4 OWNER-BUILDER DECLARATION 1 F 1
I-n] SI'FiCIAL CIRCUIT/MIST
Z I hereby a(Rrm that I am exempt from the Contractor's License w/or the
following reason.(Section 70)1.5,Business and Professions Code:Any city or
O F..� TEMP.METER OR POLE INST.
couP� any ty strwhkh requires&IsuNtromsstruct,alter,o requires th Impmvntfor demolish,ormit repair
to
anystructuretatemeits hathecIs alw requiresthettothe provisions
the )OWER DEVICES
Me a signed statement that he b licensed pursuant to the tion 7") of the
Dq We3.forb Limas l.rw(Chapmr9Ce,30mMtheonect1on70W)olDivl-
F�30 abn3afthe Bustnessend Pio(essbruCode)arthet he bemmpt there(romand SWIMMING IDOL ELECTRIC VALUATION
< the Beanbasis for the allegedpermit
subjects,
jeem)rtlon. Any violation dvl o(Sectlon 7031.5 by any OUTLETSSWRCHIESFI%TURFS —
O applicant fora permit subjects theapplicanttoo tivil penalty a.m morethan
$� five hundred dollars($50M. NEW RESIDENTIAL ELECTR .FT.
I,as owner of the property,or my employees with wages as their sole p� � STORIES 'E CONSTRUCTION
compensation,wOldothe work,and the structure is not Intended or offered for -zSO RtQ(fIW5N6
o sale(Sec.7064,Business and Professions Code:The Contractors License law
$ does not a pply to an owner of property who Wilda or improves thereon,and r �y/
whodomsuchworkhimselforthrough hlsownempluyees,provided that such
�t „tR"�a�.ppb—!o �P J�5 rOCC.GROIIP RES.UNI'1'S
Improvementaamno tendedorofferedforsale.Ithmeever,thebuildingor -,i..'go H n„r I e64Rf
Improvement issold withinomyearo(cmnpletb theowner-bullderwlll have 4r0
Xrtn of proving that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PER FEE FL'JODZONE APN
. L ,
owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
emes to ronsmed the project(Sec.7064,Business and Professions Code:
The Contractors License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA) '
Wild. or imp.thereon,and who contracts for such p,joca with a FEE SUMMARY
a�Iltf+ctor(.)licensed pursusettothe Contractors Llemee Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. Is& w
P C for this reen
Owner Date NOUTSIDEFIES
SFIODR ROOF,AILFq GOND. SANITARY Y_ N_
• WORKMAN COMPENSATION DECLARATION RECmrTN
❑T hereby affirm that I have a certificate of consent to self-Insure,or a FIXTPER IRAIr SCHOOL TAX Y N
mdlflmteofWork m'Compev tlonlmunnreoraredlfWmpythereof(Sec. RECEIIVEN
38DO,Lab CJ GAS FA.SYSTEM-1 INCA OUTLETS 6 PARK FEE Y_ N_
Policy N
RECEIVE N
Com GAS EA.SYSTEM-OOVER BUILDING DIV
ISION FEES
gnylRed
copy is hereby fumbhed. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
F-1Certifiedcopy b Bled with the city Inspection division. / ^[ G�.'zR3
CERTIFICATE OF MEMPTION FROM WORKERS' GREASE TRAP PAIDL9 Jc
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 3t1oF1' Date Remi (
(Thi.section need not be complcted If the Permit b forom hundred dollars
(5100)or less.) WATER BEATER W/VENT•/EI.FLTR ENERGYFEE Y_ N
I certify that In the performanceof thework forwhich this permit 1.issued, ��
I shall not employ any person In any manner so as to became subject to the WATER SYSTEM/TREATING
Worken'Compensatlon laws of California.Dare PAID
z Z ApplicantNEWRESIDENIIALPLMB. SQFT. Date Recei t# --
_Z Q NOTICE TO APPLICANT:ILefter making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor tQ TOTAL:
CC N Code,you=at forthwith comply with such provisions orthis permit shall be E—P— LWTBR6VL_ 3a�
CC > deemed revoked. n p o. y
— BUILDING FEE
CLC CONSTRUCTIONLFNDINGAGENCY fes, SJ K,PI VtIT -1 '� g00s -j3e SEISMIC FEE
Iherebya(Rrmthat there is a construction lending agency for the perform, TOTA . ELECTRIC FEE 3s
Zanccofthe workforwhich this permit isissued(&c.3097,Civ.C.) ZI( eb
02 Lxnders Name PLUMBING FEE —LtLbo
LL ~ LendeisAddress QTY. MECHANICAL PERMIT FGG MECHANICAL FEE a
ImnifythatlhavereadthbappR tlonandsatethatlheaWve lnfomutl
OW on
4 Iscorrect.I agree to comply with all cityand county ordinances' laws PERMITIBSIIANCE IS(V FEES PAID:
>- N relatingto Wlldingconstructlon,and Mrebyauthodzerepressnlativesofthb
Z city to enter upon the abovcnxmtloned property for inspection purposes. ALTER OR ADDTO MECH. Date Recei f#
V _ (We)agree to save,Indemnify an d keep barrettes the City of Cu pertlno
age[net liab Itles,Ndgmmn,coatssnd napenses which may In any wayacvue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
agalvt as City Inco sego sacs o(tgra_ntl00,11'.
t s rtyt
�F'wy.L aF
AIR HANDWNC UNIT(OVER 1(1,000 CFM) CONSTRUCTION TAX2(.y "I 1.91
Its
store t re / ntr.Cer Dat EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
A US MATERIALSDISCLOSURE
Wlilth a p sat r future building occupant store or handle hazardous BEATING UNIT CED 100,000 BTU) Date Recei t#
rratenal de' the Cupertino MuNtlpal Code,Chapter 9.13,and the - -3 //'�
e and&fetyCedeSection75531(a)7 HEATING UNIT(OVER 100,DOOFITIA TOTAL: /t'16
Ym No
Will the applicant or uture Wilding..past use equipment or device. VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100.0(0 BTU)
❑Yea ❑NO
Ihavc read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000BTU)
the Califomla Health&Safety Code,Sections 25Su5,25533 and 75534.1 AUGO 2 (T (
understa sad that ifthebulldlngdon not currently have&tenant,that It is my NEW RESIDENTIAL MECH. SQ.FT. FiU G a7 199';
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate o(Oeeupancy. G/'{aLt.C�Q.S L6
�
Owner or authorized agent Date vLoe0S a 61 Lees
Lf IJED BY: rYC
NOTAL: —F e
OFFICE COPY