22518 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFR.MITNO.
Building Address: GLV^ I l8 n f'1 r a� n
uw;L:re4
: one: A A
/ CITY OF CUPERTINO-BUILDING DIVISION
Co tractor's acre: LIc.Ne: APPLICATION / PERMIT i� Ift
g`') At BUILDING ELECTRICA MP BING-MECHANICAL CATEGORY CONTROL M
Architect/Engineer. Lk.No:
� �p QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addre's��„$ 1541%+- J�G6 jea/• PERMITISSUANCE 1:1 ❑ ❑
LICENSED CONTRACTOR' ECLARATION L
I hereby affirm that l am licensed under provisions of Chapler9(commenc APPUANCESRESIDENTAL JOB DESCRIIMDN
Ingwith51/eaR1on/7/0��0-0/))of—DWislon3ofthe Businessand ProfesalonsCo lie,and my _
Da
relARC NIT"MrsEo �CLARASON 1 7/-76201-1000 ANTI'S
ate
UP TO 2DO AMPS
Z. I understand my pore sha8 be used v public mounds. R
MPS SQ.FI.FLOOR AREA S/SQ.FT.
pOaE Licensed Profemiorel RICALOWNER-BUILDER DECLARATION CUIL., � Ihereby affirm that l am exemptfrom the Contractor's License law for theZO "� followin reason.(Seaton 70315,Business and Professions Code:An ciorOZt.� R yty OR EIN0Zmuntywhkh requbea pemattomretruct,alter,Improve,demolah,or repairanystmaureprlortoltsissuance,also requim the applicant for such permit to CESu file a signed statement that he h Ilcensd pursuant to the provisions of theContractor's License law(Chapter9(commencing with Section 7000)mf Divi-
LiH kon3oftheBusinessandPfessloreCWe)orthatheisexemptthercfromand OOL EL C VALUATION
S _ the basis for the alleged exemption. Any violation of Section 7031.5 by any IS-00—
,mss �ly�
<n
applicant fora permit subjects the applicant to a civil penalty of n.more than OUTLETSSWITCHESFI \J �xJ lJ`-'
five hundred dollars(¢500).
1,as owner of the property,or my employm with wages as their sok NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONST TION
C76 compensation,willdothe work and the structure have mitendedor offered for —
5 O Mile(Sec.7004,Busluas and Professions Code:The Contractor's License law
$ does not apply to an owner of property who builds or improves thereon,and as
C. R011l' RFS.UNITS
c• who doessuch work himselforthrough hisownemplayees,provided that such
improvements arc not Intended oroffered forsale.](however,the building or 1
Improvement hand withinoneyearofcomplMiomtheowner-bunderwill have
tteIlurden ofpmving that he did net bulla or improve for purpose ofsa4J. QTY, PLUM ISR •'EFTpp ZONE APN
erty,
u I,as owner of the propam exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Pralmolore Code: DATE
The Contnaor's License law don out apply to an owner of property who ALS-DRAIfi&VENT-WATER IEA)
builds or Improve thereon, and who contracts for such p(o)ecta with a
ce tt inmr(s)Bceeed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
FEE SUMMARY
LII am exempt under Sec B k P C for this reason
net DRAINS FLOOR ROOF.AREA,GOND. SANITARY Y N=
Date Y R
WORKMAN COMPENSATION DECLARATION RECEIPT
❑[hereby affirm that I have o Icanate of consent to self-ftesure,ora FI%'IVIiES PER TRAP SCHOOL TAX Y N
k 3800 cab of Worken'Compenwtlonlreuranu oraarti(led mpythercof(Sec. RFLEB'TM
lr 3300,L#6 C.) � —may CAS EA.SYSTFAf-1 INC.40UTLEIS PARK FEE Y N_
CaPolm an . 11�— CAS FA.SYSTFM-0VERd(FA) RECBUILDING FEES
Y {{ !QQ
�certinc2mpyh lire meshed. G
❑Cealfied ropy o,fled with tet cityWpectimn division. REASE/INDUMRL WASTE INTERCEPTOR PLANC14ECKFEE
CERTIFICATE OF ECEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
RhisaeaionneNnotbecompleted ifthepermlthformehundreddollars SEWER-SANITARY-STORMEA.20(IFT. Date Recei tit
(4100)afy III
that
WATER HFATFR W/VENT,/ELECTR ENERGYFEE Y N
Iron( thato any,person
an the week fors,to become
pemnjecttoit is ed, —
I shale rs employ any pawn In any manner at as to become sub)m to the WATHi SYSTEM/,TREATING
Workers Compensation laws ofGB(mrnh. Date PAID _
O Z Applicant NEW RESIDENTIAL PLM B._$Q,1T. Date Rm•.i fN
Z O NOTICE TO APPLICANT.If,after making t his Certlfiate of Exemption,you
Fshouldbecomesubjectiothe Work<n'Compersatlon pmesiore oftbe Labor
W Cade,you most forthwith comply with such provisions orthis permit shall be TOTAL:
LU > deemed revoked. BUILDING FEE
d p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyaffirenthat there h a mrtatrualOn lending agency for the perform- ELECTRIC FEE
O ane of the work for which this permit h Wued(9ec.3097,CIV.C.) TOTAL:
u _ Lcaders Name PLUMBING FEE
LL H Lcndcrs Addmres QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iceaifythatlhave read thisappBaumnand aatethat theabove information
d "correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r U) relating to building mretruction,and hereby authoI representative of this
Kcity to enters nthe she -mentioned property for inspection purposes. TFRORADDTOMECH.
(We)agree demnify an d keep harmless the CI nr On m Date Receipt»
Zagabut nabiffic p censer, expenwawhich anywa AIR HANDLING UNIT(TO 10,O3o CFM) $U$TOTA L:
inn said Cl n oft he grantagedt milt.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX
Signa re AP r Date EXHAUS'THOOD(W/DU2T) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCL SURE
ill the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,00 BTU)
material as Date
defined by the Cupertino Municipal Code,Chapter 9.12,and the _ Recei t#
I IrAth and Safety Cade o 25532(4,)7 HEATING UNIT(OVER 100,0008TU) TOT L,
❑Yn L9411% —
Will the applicant or futurebcilding occupant useequipmentordevices VFNTLATION FAN(SINGLE RFSID) IBS11-,t hrr-m DATE
emi
t hazardous air contaminants as defined by the Bay Area Air pgK{OYI�`L
Quality Marcel, IDlstrict7 BOILER-COMP OFR'OR 100,000 HIMyes
J/' UU I
4ha read te17 i hrequlrcm rats under Chap .95 f BO LER-COMP(OVFR]00,000BN) ' �Q
b!!� M a�
the Californi Health k Safety Code,Se ons2550 25533and . I 19@*
ndemtan hztifthe buildingdoen corm haveaten ,tha Isery NEW RESIDENTIAL MECH. SQ.I7.
c naltythe occupant a irenpnts ch sr'be met fJI
ide el
prior race Cert 4,(O nq. all���g66 jj��
ner or auth at D. t6
TOTAL: ISSUED BY: �(J
OFFICE COPY