22922 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
suiming Fro ect Identification O,
bAdd.:Build .A .: �� �1 Lxt Pg TN22922
CITY OF CUPERTINO-BUILDING DIVISION
^ tr
APPLICATION / PERMIT ^ �J
¢ Fi BUIIDINGELBMKALML RINGMECHAN'ICAL CATEGORY CONTROL It
Archxed/Fsgforer. Lb.Na
QTY ELECTRICPERM F FEE BUILDING PERMIT INFO
Add. - PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirundutl am li under pmvhiaam of Chapter 9(nanmen APPLIANCFSRESIDFNTTAL I JOB DESCRIPTION
ingwith Section 700MofDiv .3o(1 BuYnemand Pro slonsCode,and
Lim, x b in full fo d dfxi---= � PANELS M J O
lice.is
Ile/ ���1
Date 4 Contractor UP TO 200A�
ARCHITECTS DECLARATIONAMPS
0'Z Iundentand mypbmshaBb,tued aspublleremrda OVER IOW SQ.FT.FLOOR AREA
O
oLicensed Profealonal L
�¢ OWNER-BUILDER DECLARATION
Ihereby affirmf)ut l am exempt frmnthe Cootractor'.Ll¢nr Lwf 1 CRC /
following m..(Section 7ml5,Buelnew.rd Profeulonu Code My city or
FP co ntywh"reqube,apem wmrmtruct,alter,impm ,demolbh.orrtpalr .METER OINSTn
anyYrodurt priorto lm feaaarce,oleo rcqulrotheappgantfmsuch penNtta POWER DEVICES
1 Ric a aligned]statement that ha h licensed pun uant to the proviebrm of Ne
;µG Contndor9 Ureme Law(Chapler9(commencing wxh Section 700D)of Divi- gWpTIsgNG POOL ELECTRIC
O< Won3ofthe Buelneaand Profealom Code)orthx heheu thertfromand VALUATIO-9�•
tP S"•� the bfor the alleged exemption. My Nolation of Sentient 7015 by any ^ O OO T�'-�
vh
p'4 pPB¢nt for a permit subjects the applicant to a dull pevxy,dnot more than OUT-E'SW]TCHESMTURES `
7 fhnhundmd dollars(T.SOU).
A' 1,an owner of the NEW RESIDENTIAL ELECTR dT.
property,it the
out
wages theresole BQ SIOWES TYPECONSTRUCTION
tale&compeIatlon,Boaleee, work,if.W strode: knot InteMed aroffandfor
D sale not 7014,Bart owand Profoerty Code:The or juratlor.hewer,doxnsc I and don not apply to.nownerdproperty whonemorlmproveethem4and ch OCC.GROUT' RES.UNITS
ImPmvewho d. ,nth,uh amrkMmsededolf our roffo Naowne.If,hc eprwl elued thatsuor
Improvementsartnotintended orrofc forests.If,however;theerlWhxon TOTAL
Improvemeru haoM wxhinoneyearofconsplxb4the wvnerW 1lderwWhave
try mien of proxing that he did oa Wild or Improve,fee purpose of sole.). QTY. PLUMBING PERMIT FEE FLOOD ZONE ApN
Ll Las owner of the Property,am exclu,Wely contracting wgh 11¢rud
contncton W mwtrvct the project(Sec.70K Bu,inenard Prof.W.Code: PPRMITISSUANCE
The Contractor's Lice.haw does ect apply to an owner of property who AL.�(-DRAW A VENTWATFdt ,
Wild. or imp.thereon, and who coMada foe aueh pp,"jecb wW a �
c7WPctorta)lameeed perwaet to the Conrarmes Lioen.e Law. BAOCFTAWPROTFLT DEVICE FEE SUMMARY
LII am exempt under Sec B &P C for thin ¢ ni
nen DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y_ N. .
Owner Date .
•
WORILMAN COMPENSATION DECLARATION E❑I hereby affirthat I have a cedTDate of consent to self-Insure,or a FDCMTRFS.PER TRAP SCIi00L TAX Y
m _ N_
¢ ffi t ofWorkers•Compen mImran¢mamrtR copythereof6ec. RECEIPT
38p,IAb C.) GAS EA.SYSTEM-1 WC4OUIEIS PARK FEY Y_ N_
I,oiCokyav-
_ GAS FA.SYSTIId-0VFRd(EA) BUILRIN�DING VISION FEES
ertRledcopyhhercby fumlahN. GREASE/W`DUSIRL WASTE INTERCEPTOR PLANCHECK FEE
CertiEed mpy b filed with the city irupection dlWaion.
CERTIFICATE OF EXEMPTION FROM WORKERS GRFASETRAP PAID
COMPENSATION INSURANCE SEINER-SANITARYSTOP-M EA.20UFT. __Date Reeciptit
(Itch I..) need rat becompleted Uthe perrtdt bf¢one hundred daBars
61DD)«lea.) WATER HFATERW/VENT/O.Fi'1'R ENERGYFEE Y N
I¢rtUythx Nthe perfannan¢o(the w¢kfor which tid,pemdt le basad,
1 shall not employ any portant ts any manner so as to become subj o to the WATER SYSCE7d/TREATING
Worker Compensation Lw,of Ca Womb. Date PAID
_Z NOTICE TO APPLICANT.It,after muking t his Certificate of Exemption,you NEWRESIDa U L LS,M SQd•T. Date Re i t#
should become subject to the Workers'Compematlon provisions of the Labor TOTAL
F N Cade,you must forthwith comply with each pmvislosm or thin Fermat snail be,
W > deemed DUILDING
CONSTRICTION LENDING AGENCY SEISMIC FEE t
ll IherebyafRnnthatthartba comtrectiou lending agency for the perform TOTAL: ELECTRIC FEE
7 Z arm ofthe work for whkhthb;rout h laneed(,13097,Cl,C)
'U O 1,enaer.Name PLUMBING FEE
LL r LeMce,Addm, QrY. MECHANICAL PERMIT FEB MECHANICAL FEE
DEW I ¢difyth lnavertadthbapp"tbnaM,tatethethe abovelnfomrutiou
a hmtte Iagrtetommplyw aUctyaMoountyoMiunrn dmatetant 5
PERMIT IUANCE FEES PAID:
>_ N refxingtO bullellegmmtrudlon,and hereby authorfre repnexntatNeaofthis
F Z dtyto enterupon the above-mentlored pproperty fee Inspection purpo� D
ALTER OR ADTO MECH.
_ (We)agree to saw,,indem dfy an d lu,p narmlea the City of GrpedLia Date Receipt#
.ga bWtkm,}sdgnrn4 nests.sol expenseswhkh mmyb,anywayacaue AIRHANDLING UNIT(TO 10,000CF147) SUBTOTAL
sexy m aanaqueneeofthe thi.Permit. nIR HnNouNC I1NTC(OVER I0,0)0 CRM)
CONSTRUCTION TAX
naturto ant/Contractor m EXHAUST HOOD(W/DUCT). CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theapp0¢ntorfuture Wilding occupant store.,handle hariml ue HEATING UNIT(TO IOIpDD BTI!)
material aa defined by the Cupertino Municipal Code,Chapter 9.13,and the RCCeI I#
Health.M SafetyCade Section 35572(.)3 HEATING UNIT(OVER 10,000 BTU) TOTAL.
❑Yee No
Will the appliance turf Wilding occupant useequlpmerd ordcv VENTILATION FAN(SINGLE RESTD) 3 I$ CE DATE
which endt harardexsair mnlamWxaas defined by the Bay Area Alr �rIV 1
Quality hlarugensent Dbtrlct7 BOI11R"NMP OHPOR I00,M BTU) _
4 Y� No QF CUPEti(INU
havereadtheh No
nbunderChapter6.95of BOR.ER-COMP(OVER IMODD BTI)
II I
the CaOfamb Health A Safely Code,Sections 35505,75537 and 15531.I c5D
uMenbMyt..ohe the occp..rwlarrently eq.1m entatenan4riot ithmy NEW RESIDEN77AL MEIN. SQFI'
rapovlbBlty to edifytheaatcof oftherequirementswhich ndst Wmet
prbrto bsuanen ofaCedlflate ofOaupancy.
Owneror authM agent Date ISSUEDBY'
TOTAL:
OFFICE COPY