22463 APPLICANT TO FILL IN INFORMATION WITHIN RED LIN EST'�— USE BALL POINT PEN ONLY
. Bulldin Naiad identification IAV l M� PERMITNO.'
Building Address: 22463
_ 10 700 ►J � 106Aer1.� QWfl � sNFI_,_
nes one:
'Rep �lr*M%3 PPI�i9Q 5 CITYOF CUPERTINO-BUILDING DIVISION
• Contra Name: Ue.N. APPLICATION / PERMIT
BUILDING-ELECTRICAUPLUMBING-MECHAMCAL CATEGORY CONTR011tf SYC
Architect/Engineer: Llc No: l0I
/
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addreac PTRMITISSUANCE ��
LICENSED CONTRACTOR'S DECLARATION
Ihereby
ectloarmthat am licensed h"O. 3ofthederpressand sof Cs5ioms9de,and c APPL[ANCESRESIDEN77AL ]OB DESCRIPTION
It..I isful7000)ofdeffecn3oflheBupnemandPro(caponsCode,andmy PANELS
license la In full force and died. /
LicenseChu
Date Contort
ncior
ARCHITECPS DECLARATION - 2014000"PS
q�q�ua Ore OC I understand my Ohm aMI be used u I"''public records. OVER 1000 AMSQ FT MOOR AREA
to (a Licensed Professional SIGNS ELECTRICfia-
C 7 ei
GGGG"a�Ltll OWNER-BUILDER DECLARATION �7 1 J
z�o, I hereby affirmlhat l amexempt from the Contractoes License Law forthe -
O Z following naso..(Section 70115,B.Mrmx and Prof®ions Code:Any cityor s L
C� countywhlch requirma permit to construct,alter,improve,demoWh,orrepair
arystmcham peiorto lb Wuance,aborequiresthe applicant forsuch permit to ppyyER DEVICES
Iy ilk a signed statement that he h ilcenaed pursuant to the provisions of the
Cont.d.e.License Law(Chapter 9(mmmentlng with Section 7000)of Disk1QTY.
VALUATION
sion3oflheBupnemwdProfemWmCade)orthathehemmptthemfmmand
the basis for the staged exemplion.'Any violation of Section 70115 by any ,appllantforapermilsubjectstheapplicanttoacivilpenaltyofnetmorethanTSSWTTCHESFIXTURESL..y-�five hundred dollars(5500). SQ SIDRIFS CONSTRUCTION
ESIDENI7AL ELECTR Ff.I,as owner of IM properly,or my employees with wage ea their outscompensation,wlldo the work andthe structure b not intended or offered fornrete6ce.78♦4,BYaiM9aa.dPmf.m .COde:TheCOnldoe.Li.R lw
does not apply to an owner of property who Wilde or improves thereon,andOCC.GROUP RFB.I/NrTS
who doessuch work himself orthrough hie own employee,provided that suchImprovements are net Intended or offered for axle.][however,the building or TOTImprovement hwldwithinomyearofcomplaton,theowner-builderwill have
en of provingthat he did nmWild orlmprove for purposeafsaleJ. PLUMBING PERMIT FEE' FLOOD ZONE APN
owner of the property,am exclusively contracting with licensed PERMITISSUANCE �s
ntncion to construct IM project(Sec.7044,Business and Professions Code:
The Contnctoes License Law don not apply to an owner of property who
Wilds or Int rove thereon,and who contracts for such ALTER-DRAIN&VENT-WATER IEA) FEE SUMMARY
on
5actor(-)licensed pursuant to the Contra toes License Law,%�with a
LI I am exempt under See. B &P C for this Mason BACK FLOW PROTECT.DEVICE
OUTSIDEFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Owner Dae RECEIPT p
WORK MAN COMPENSATION DECLARATION �.�S PER TRAP SCI{OOLTAX Y N
Ell hereby affirm that I have a certifiu[e of consent to self-Insure,a a RECEIPT 0
certificateofWorkers'Comperoatlonlmurance or a certified copy lhemoft5ec. GAS EA,SYSTEM-1 INCAOUTLETS PARK FEE Y N
3800,Lab C.) RECEIPT N
PWIry tl
CO any GAS.EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
9"
rttil
Certified copy b herebyturnlahed. GREASE/WDUSIRL WASTE INTERCEPTOR PLANCHECI&e{ss'Z��
Ceed mpyhfiled with the city Inspection division. �}
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP - PAID^-a-
r '�TDt
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.700FT. Date Rcce!i t#
(This section need not be completed tithe permit is fee one hundred dollar
(5100)mlem) WATER HEATER W/VENT/EL(CTR ENERGY FEE Y N
Icertlfythat In the performance oflhework forwhich this permit is Weed, //��
I shall not ekemploy any Person In any manner w asto become subject to the 'i qp (pOOa
Workers'Compensation laws of California Date WATER SYSTEM/TREATING PAID?
OZ Applicant - NEW RFSTDENTIAL PLMB. SQFT. Date RCceI t#
Z O NOTICE TO APPLICANT-.If,after making this Certificate of Exemption,you
should become subjed to the Workers'Compemal ion provisions of the Labor - TOTAL: a.
N mo
CC Code,you at forthwith comply with such prosialom or this permit shall be L G FEE
W , reI
dssed revoked. /9�,a�—.y
CONSTRUCTION LENDING AGENCY SEISMIC FEE f_arYti� 1
CL F3 Ihembyaffirm that there b a construction lending agency for the perform TO ^e ELECTRIC FEE
Z Lenderlhe work(or which this permit is Issued(Sec.3097,Civ,C.)
V O IciWer'e Nanta PLUMBING FEE
LL F Landers Add mm QTY. MECHANICAL PERMIT FEE
O W Imrtlfythatlhavereadthsapphatbnand statethattheabovelnforrmlion MECHANICAL FEE
(1, iscomect.l agree to compiywith all cityand countyordlnances and elate lawn PERMIT ISSUANCE S— FEES PAID:
N relating to building comWciion,and hereby authorize representative.(this
F Z cityloenterupon the above�rmstioned property for Inspection purposes. ALTER OR ADD TO MECH. Date Receipt#
Me)agree to save,Indemnify an d keep harmless the City of Cu perlkw
V
against liabNties,judgments,cups and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,OW CFM) SUBTOTAL:
ags 1 CI Inst f anting fthl permit
/ +A✓D� _ AIR HANDLING UNIT(OVER 10'"CFM) CONSTRUCTION TAX Qa
Signature. pp"cant/ ontracior Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARDOUSMA ERIA RE
Wllltheapperant car future bulldl pant re rhandlehavrdous HEATING UNIT(TO 1(0,000 BTU) Date Recd tit
material as defined bytM Cupertino u cip'IC haptcr9.lZaodthe
Health and Safety Code Section 75537(a)7 HEATING UNIT(OVER 100,000 BTU) TO
❑Ye No
Wllllhe applicant or lure building occupant use equipment or devkm VENTILATION FAN(SINGLE RI3ID) .ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Arca Air
. Quality Management District? BOILER-COMP(3HP OR 100,000 BTU) -
I—I YesI— No pp
ave read the hazy oue materialsmaterialsrequiremnnb under Chepter 6.95 of BOILER-COMP(OVER 100,000 ITV) B'pp�N K '
the Califmh Health&Safety Code,Sections 75505,75533 and 75534. I
understand that if the building does not corrcntly have a tenant,that it is my NEW RESIDENTIAL MECH. SQFr ����
reapmruibl
lty to notify the occupant of the requirements which=at be met OCT 2
nee cy.
.eros oath sized agent Date - 4 ISSUEDV OF CUPEHTINU
0T
OFFICE COPY