22462 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification w t L p s PERMITNO.
B"°ding Addmec 22462
b �� W S F+6LL
wm . erre: one:
CITYOFCUPERTINO-BUILDING DIVISION
Co.m Mam`e,: ,,.J, g / Lm.No: APPLICATION / PERMIT
PG&''L I -f `�c{�y�y l t• BUILDINC-ELECTRICALPLUMBINC-MMILAICAL CATEGORY CONWS-q f�
ZJ
Arch teArch—En F-F—T I ) Lk.Nm (O'
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE W I t
LICENSED CONTRACTOR'S DECLARATION Irk
I hereby affirm that l am Bmnsed under provisions of Chapter9(mmmmrr APPLIANCESRESIDENTTAL JOB DESCRIPTION
ingwith Secdon7000)of Dlvlalon3ofthe Buslnessand ProfeaslonaC„oda,and my -
limme Is in full farm and affect. PANELS - {,L 1
LI...Class Licp S 11FL_I.— 6W1��/
Date Contractor /
ARCHITECP5 DECLARATION 201-IOW AMPS
m0 2 I understand my plaru shag be used as public records. - OVER 1 OOO AMPS ` `SQ.Far.FLOOR AREA $/SQ.FT.
k U0 f� Licensed Protemlonal SIGNS ELF+hj '{i ` 6i
d�< OWNER-BUILDER DECLARATION SPECIAL ?/ ` d '
AH iP Lfl
u?7 I herebyafBrmthat I amexempt from the Contractors License Law for the
Z q following rea.on.(Section 7031S,Business and Profmions Code:Any city or t�
0 '� county which rcquLm a permit tomnstruct,alter,improve,demolish,or repair TEMP. ORl'�L I
EL a anyctructurc prbrmila Issuance,alsorequUeethe appllmntfonuch permit to IVWF.R DEVIATE
f f l U file a signed statement that he V Licensed puauant m the provislom of the
�OSContractor'.Ltca.law(Cha er 9(mmmencin with Section 7000)o!Dlvl-
sion3oftheBuainm and PrvfemleneCode)ortM1aBhelaexempttherefromand `ItriNSwaGPOOL ELECTRIC _ . r_,VALUATIO"!..�.,�_
0 5 the basis for the alleged exemption. My violation of Section 7031.5 by any OUTLETS-SWITCHES.FIXTURES (`I rIa O I�.O/ QG —I
'991 applicant for a permit aubjectathe applicant to a civil penalty of not morethan VV -1 1
five hundred dollars(5500). �_—.
I,cue owner property, NEW RESIDENTIAL ELECT° SQ,FT. STORIES ' -"tB CONSTRUCTION
�n ❑ p perry,or my employees with wages as I lu tr sole
mperuadon,will do he work,and the mochme la not Intended or offered for 2
Osale(Sec.7000,Busttussend Professions Code:The Contractor's License Law
dues not apply to an owner of property who builds or improves thereon,and
�^ who doessuch work himself orthrough Msown employees,provided that such OCC.CROUP RFS.UMTS,
improvements are not Intended oroffered for sale.IThowever,thebulldlogor TOT Vpf
improvenenti widwithlnencrarofmmpletlom theowner-builderwill have
t enol proving that he did not build or Improve for purpose ofsale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
ntmd rs to construct the project(Sec.7044 Bualne®and Prof esslom Code:
The Corunicb is License Law dm not apply to an owner of property who ALTER-DRAIN&VENT-WATER(FA)builds or Improves thereon,and who contracts for such p(o)ects with a
cgnL ctor(s)limned pursuant to the Contractor'.License Law, FEE SUMMARY
LJ I am exempt under Sec. B &P C for this twson BACK FLOW PROTECT.DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
• Owner Date RECEIPT p
WORKMAN I haw aNSATION DECLARATION FUTURES PER TRAP SCHOOLTAX Y_ N
❑1 hereby.!firm that I have a mrti(imte of consent to copy
tnwre,ora RECEIPT e
cert1(Icate of Worken'Comperoatlonimurance oracer[Ifled copy thereof(Sec. GAS F.A.SYSTEMA INCAOUTLETS PARK FEE Y N
3800,[ab Cd RECEIPT M
Policy p CAS EA.SYSTEM-OVERd(EA)
BUILDING DIVISION FEES
Com any
CCertined copy is herebyfurnished.the city GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECKF o
�Cenifled copy V filed with the city Inspection dlvlelun. GO
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP ppip leL'l� I 1�92trj
COMPENSATION INSURANCE SEWER-SAMpARY-STORM EA.2WF7. Date RCCCI tM
(Thlsm WnneednotbecompletedlitheperMt laforanehundreddollars
(5100)mlea.) WATERHEATERW/VENT/ELICTR - ENERGY FEE Y_ N_
I ll am employ that in an pelf.1.anynce of mohe er.rk as to cern een subject
to if.ed, fr r1pGm
I shall not employ any prawn in any manner n a m become wbjM to the WATER SYSIL.M/IREAlING "I'iM I
Worken'Compenation lavnof Callfomla.Date PAID
Z Z ApplicaNOTICE
NEW RESIDENTIAL PLMB. SQFT. Date Recet t#
O should ETO APPLICANT:to the
after making this Certificateof Exemption,you
should become subject lathe Warken'Comperuatbn provhisper the Labor IOTA s.
U) Code,youmuatforthwithcomplywithsuchprov9iouorthlapemdlNalibe lUe- o V1Z� ?la BU 3 $3gISO
w ?
G dmmed revoked.CONSTRUCTION LENDING AGENCY Z -`T �D'QT V-� EISMIC FEES •�
CL I herebyafflrmthat there is a construction lendingagenry forthe perform IOTA a� ELECTRIC FEE .
7 Z anmo(the work for which this perMt Is Issued(See 3097,C1v.C.) -16 DF p L�
U O 1arWer'.Name PLUMBING FEE
I- Lender.Address QTY. MECHANICAL PERMIT FEE 6
LL MECHANICAL FEE
OO Icerti(ythatl have madthlaappBmllonaM Here thattheabove ln(ormatlon /My�
aIs correct.I agree to comply with all city and county ordinanm and state law. PFRMTTIS5UANCE W FEES PAID:
} W relating to building mtntrucilon,and hereby authortm representatives of this L.I�1 r
igiai5e/
bcvcmentkmed property for Impaction Pu ALTERORADDTOMFCH.
2 Indemnify an d keep harmlm the City o Cu Date Recei t#
V againstents,"sand expenses which y1 AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
2200 erne t acting of ml. e CONSTRUCTION
` AIR HANDLING UNIT(OVER 10,ODOCFM)
Sigoaturcol AppBmnt/ ontratlort EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PA
HAZARDOUS MATERIA DISC R
Will the applicant or future bull ding ntatoreo ha ardma HEATING UNIT(TO 100,000BM Date Rmei t#
material as defined by the Cupertino Municl ICW,C apt.r9.IZ..dthe
Health and SafetyC coon 25532(.)7 HEATING UNIT(OVER 100,000 BTL
❑ Ye. No
Will the applimntor rebcildingompantoucquipmentordevima VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air comamlMnts as defined by the Bay Area Air
Quality Management !Lt ? BOILER-COMP OHPOR 100,000 BTL r�
4Yeno
haveresdthe bazx ousmaterialsrequirementsunderChapler6.95o( BOL�RCONP(OVQ 100,00 BM
the California Health&Safety Code,Sections 25%5,25533 and 25534.I Q r'rZ"
understand that if the building dors not currently have.tenant,that It b my NEW RESIDENTIAL MECH. SQ.FT. 1 1 if i
resporoibllity to notify the occupant of the requUemonte w ch ! Y
rbr to La an daCartificatooflacm a
Al
_ �o o L lsilw �I�Of
OGua� %nn
w r r out or red agent _ to ISSUED BY: m
IOTA �
OFFICE COPY t