22425 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildln Project Identification PERMITNO.
B"IldingAdd�\' 22425
d9 JUN R.T 21J4
come:
ral A14 E FtfiG'/IC FS9 CITY OFCUPERTINO-BUILDING DIVISION ,n
contractor' an.: l m Lb.Nm APPLICATION / PERMIT ()
Cf IQ. CIexcQ BUILDING-ELECTRICALPLUMBiNGME LAICAL CATEGORY CONTROL$
Architect/Engineer. Lk.Net
10-79_ � v j,
Q ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address N C 4S/2/v PERMITISSUANCE ❑ ❑ ❑
LICENSED ACTORSDECLARATION
I krebyaMrm that lam lkmsedunder prwatlov ofQupter9(®rmhrnc APPLIANCES-RESIDENTIAL JOB DESC
RI
Ingwlth SMbn 7000).(Divlston3ofthe Buelneeand Pruf sudesu Code,and nyy
I..la lnfulforseandeffeci. PAN Is
Lfmnac Clan Lb$
Date Contractor —UP TO 2DDAMPS
ARCHITECT'S DECLARATION 2014000AhtI5
0 C20C f understand my plavahall be used its publlcrecords, OVEKl(KX) P5Q /SQ.FT.
�U Licensed Profesbvl �NB�.TR«A. T E R
�< OWNER-BUILDER DECLARATION SPFLIALCIXCIIIT/M15C
Ihembyaflim that l am exempt from the Contractor's Llam
n [Aw for the ^!
pppppp following mason.(Section 7MI5,Bhubm and Profmsb Cade:Any city or GJ
K F'u( (vuntyww mquB apemdltomns d,aBer,lmprove,demoah,ormpair TEMP MEIOR1'OI.E I
NST.
W'a as /
�L anystructurc prim to lb atsuarce,alw reyu0etheappBcantfm ouch pemdt to POWER DEVICES
K file a signed statement than he b t1c rued pnrauant to the provisions of the
0 uu.r Contractor's License Law(Chipter 9(curn encing with Section 7000)of DM- SWIMMING POOL.ELECTRIC UATE
O aton3ofthe Butinesand ProfmbmCade)orthatheatexemptther mmand VAL
the basisfor the allegedexemption. Any viaWbn of Section 70115 by any ,3 ") Oa
U
ppH.t for a permit subjecm the applicant to a civil penalty of not more t han OUTLETSSWITCHESFDMJRES `[J
ed red ddlus(5500).
A I,an owner of theproprrty,or my employee with wages u theb sole NEW RESIDENTIAL ELFLTR SQ.FT. STORIES TYPECONSTIV.CHON
t rnTpevation,will do the work,and thestm¢ure b rot intended or offered for
5 O s+k($I 7061,Bualvu a"Professions Code:The Cmunict.e.License Law
f$ don not apply to an owner of propertywho buldsor improve thereon,and OCC.GROUP RES.UNITSwhodoes.uchwork himaelforthrough wownemployees,provided that such
Improvements are nm Intended oroffered for mit.14 however,the W Ilding or TOTAL:
Improvemcmbsaldwhhlnorcyearofcuplekb thewvnerbullderw love
VI,
en of proving than he did not wfld or improve fm purpose or cafe.). QTY. PLUMBING PERMIT FEE FLCODZGNE APN
as owner of the property,am excbsively contracting with Becowd PERMIT ISSUANCE
to consumer the project(See 7061,Businessand fes
I#obns Code:
The Contractor's License Law does net apply to an owner of property who
builds or improve thereon, and who mmram for such ptgeets with a ALTIIYDRAINk VENT-WATER(FA)
e* +erm(s)Ilmrhacd pusuanttothe Contetlds Limnsel,aw. BACK FLOW PROTEGE'.DEYT� FEE SUMMARY
LJ I am exempt under Scc B h P C for this reason
^ DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Dee
WORKMAN COMP FNSATIONDECIARA OT�N I— mss
-MI hereby affirm that I have a certificate a consent to self-bsurc,m a FIXTURES PER TRAP SCIR L TAA Y N
certificate of workeni Compensm on
ation loci rana mrtuled ropy thereof(Sec. RECEIPT
3800,Lab C) GAS FA SYSTpM-1 INC1 OUTLETS PARK FEE Y_ N
Pdky Y GAS FA.SYSIFM-0VER 4(EA) RECEIPT
Com any BUILDING DIVISION FEES
Certified copy Is hereby with
the ed
city GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
F-1 CL 61 copy b rued with the dry inspection dldslon.
CERTIFICATE OF EXEMPTION FROM WORKERS GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARYEA 3'%&'1. Date Recei til
(Thbseetbn need net becompleted B the permit at/m one hundred dollen
Will))orlessOWATER HFATFRW/VENT/ELECTR ENERGYFEE Y N
Imrtlfythymatin the perfornvrhce ofthewamk forwMchuwpemdtVatmed,
I slue neat employ any person In.ray canner m as to become object to the
Worken'Conpewtbn l�sys mfGWorn4.Date WATER SYSTEM/TREATING PAID
-
z O NOTICE TOAPPLICANT:B ,after me4inglw CertBlcate of Exemption,plicant NEW RFgDFNRAI FLMB' �tT Date Recel t#
N should become eubject to the Wmiceri n Compensation provisions of the Labor r TOTAL
Code,you conn folhwfth comply withouch pmvat m orthh pemdt ebull be
> deemN revoked. o D
lL —O CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Iherebysillfcthat there b a mvtruction lending agency for the perform ELECTRIC FEE
Z anceofine workrwhbh that permit is Lowedec S3097,CIv.C) TOTAL:
U O Lender.Na PLUMBING FEE
U. F Under.Addhes QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W E mdify thatl have read tow application and satethat theabov<baommion
bcorrcb.EagrcetocomplywhhalldtyaMm ntyordbanmand statelaws PERMIT ISSUANCE FEES PAID:
} N refining to building construction,and hereby authorize represenhtivn oftw
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
V — (We)agree to rove.Indemnify an d keep armless the City of Cupertino Date Receipt#
aga0ut abiBtka,judgments,cortsand expenses which may In anyw.y..c AIR HANDLING UNIT(TO 10,0)0 CFM) SUBTOTAL
ysltiyid
agad City In mnsegoenmgranting ofso 0.
Il J[ AIR HANDLING unTr(OvFtF 10,000CFM) CONSTRUCTION TAX
7b
Signature of Applicant/Contractor to EAHAUST HOOD(ns/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant urfihtm building occupant nom or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the y—�
Health and Safety Code Section 25532(1)? HEATING UNIT(OVER 100,000 BTU TOTAL: -y v
Rut uNo
Il the.pplkard r tum building occupant use cquipmem or device VENTILATION FAN SINGLE REM) ISSUANCE DATE
which emit hazard.air contamLunts an defined by ted ay Arca Air �a
Quality Management District? BOILER-COMP(3HPOR1mm0BTU) PAID
❑� Y s No 1 Thawread the haasmateri+b mqulmmenb under Chapter i95 of BOMER.COMP(OVER 100,000 BTU)
the JVL 0as
California Heafth k Safety Code,Sections 25505,24533 and 25531.I
01
understand thatlflhabuildingdoenotmrrcntlyhaveatenantthatltbmy NEW RESIDENTIAL MECI-L SQFT
responsibility to notify the excupant of the requitement.which most be met
Prior to usuance of a Certificate of Oavparhcy.
Ownermaulhorired agent Date RUED BY:V aI�fV
TOTAL 11--ere--
OFFICE COPY