22585 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Addmes: nI"I (�
ar. GG j8
Dara ante. one:
CITY OF CUPERTINO-BUILDING DIVISION
Contractor's Name: - LIc.N. APPLICATION I PERMIT
fidolm PnmatiLIT& !Lt4'rri46 2.1ZVbf' BUILDING-ELECTRICALPLUMBINGMFCHAMCAL CATEGORY CONTROL
rthltect/Engineer. Lk.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO'
Address "6 sfAM�O A YY PERMITISSUANCE �� ❑ N:;" ❑ ❑
LICENSED CONTRACTOR',D:CIARATI N I/—J
I hereby affirmthat l am licensed under provhlons of Chapter 9(coenmene- APPLIANCES-RESIDENTIAL ]qBDESCRIPTION
Ingwllh Se ion7000)of Divislon3ofthe Buslmuand Prefesionscede,and my
license In In full�f rt-e and effect. PANELS
License Chsa�Lk.# IL4%
Dates��Contractar
ARCHITECPSDECLARA I N
201-IMOAMPS
set lundenland myphnsslaBW used uro
publlererci& OVER1"AMPS SQ.FT.FLOOR AREA S/SQ.FT.
CO
��j Licensed Professional SIGNSELECTRICAL
g OWNrn eBUILDER DECLARATION SPFGIALCIRCUIT/MLSC O
ZE, Iherebyaffinnthallamexempt from the ContractorsLicense Law for the
following mason.(Section 70315,Business and Professime,Code:Any city or
F. TEMP.METER ORPOLE[NST.
rou
K ntywhlch rcquiresaperMtrororutruct,alter,impmve,demolbh,orrepalr
anystructure pdorto its issuance,ahorecia esthe applicant forsuch permitto )OWER DEVICES
file a signed statement that he h licensed pursuant to the provisions of the
Oµ Cummeme,License Law(Chapter 9(comemecingwithSectlon7000)ofDivl-
�0 Bion3ofthe Bualms..dPefeclom Cods)orthat he h exempt therefromand SWIMMING POOL ELECTRIC VALUATION
0 the bash for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITCHESFIXT"URFS
appbmntforapert tsubjedetheapplicanttoadvilpenaltyanarmrethan
$ five hundred dollars he pr. NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPECONSTRUCTION
❑e a owmr ldot properly,army empt es in with wages r there sok
�7 compensat044,wflBeelee..andhe P,and freaki struciurehna intended License
d for
salLaw
5O doe nec.tappy to an ow er of property
build@C Improves License Lnd
$ who net apply torn owner ofpropertywhobuildsorImprovesthereonand OCC.GROUP RES.UNITS -
whoovessuch mentsa netinthimself e orsugh Msow employees,
enveprovided that each ding or
improvements arena Wended omyearofc=pleroffered formic.the& nvebugder ilIhave IOTA `(�
improvement b wid within omyearofcompletkn,the owner-W Bderwlll have
tt(Ltiurden of proving that he did not build or Improve for purpose ofukJ. QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
L j L an owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 70K Business and Predmic ns Cade:
The Contractors License Law don net apply to an owner of property who
Wilds or Improves,themon,and who contracts fee such p(ojecot with a ALTER-DRAIN&VENT-WATER(EA)
cgat)aaor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
LI I am exempt under Sec B &P C for this reason BACK FLOW PROTECT.DEVICE OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,CONTE. SANITARY Y_ N_
RECEPr N
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
F11 hereby afftrm that I have a certificate of consent to self-Insure,ora REGI NN
ceNOcesofWorkeci Compensatloninsunnceoracertlfled copythemof(Sec. GAFA:SYSTFM4 CAOUTLEIS RK Y N
3800,lab C.I S WPAFEE
Policy RECEIPT 0
GAS EA.SYSTEM-OVER d(FA)
Com ny BUILDING DIVISION FEES
Certlflcd copy hhemby(umlehed. GREASE/INDUS[RL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKER,' GREASETRAP PAID
COMPENSATION INSURANCE ,EWER-SAFIITARY-STORM EA.200PT. Date Recej t#
(This section need net W completed If the payout 6(mone hundred dollars
(f10(forless.) WATER HEATER W/VENT/EL CTR ENERGYFEE Y_ N_
I certify that In the performance of the work for wNch this penNt Is blued,
1 shall not employ say person In any manner so as to become sub'ct to the WATER SYSTFAf/TR[ATING
workors'Com;mtiYn Ia�'$of Californh, Data 9�11�..� PAID
Applica.Z Z NOTTCnt %n_TLY�efir-" - NEW RESIDENTIAL PI.MB. SQFT. Date ReCCi t#
0 NOT)CETOA,subjetto theWorkere Compng bCertnluteof Exemption,you
H Code,shoulyou
=at subject the Work en'Campeumlon provhlm permit s Labbe TOTAL:
W Code,youmuatforthwilh comply with each provisions or this permit shall be
W > deemed revoked. 6U LNG •
a FS CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affimnthat there h a construction lendingagenry,for the perforce, TOTAL: ELECTRIC FEE
Z anceof the work for which this permit Is Issued(Seo 3097,Civ.C.)
O O lcruces Name PLUMBING FEE
LL F Landers Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OU I certlfythat l have read thhappllcetlonand Ratethat flu,,6welnfomutim,
a licences.l agmeto eomplywlth all cityand countyordinanen and state laws PERMIT ISSUANCE FEES PAID:
). relating to building construction,and hereby authorize representatives of this
W city to enter upon the above-mentioned property for Inspection purposes. ALTER ORADDTO MECH.
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V
against habWtles,judgments,mss and expenses which may In anywayaceree NR HANDLING UNIT CTO 10,0(10 CFM) SUBTOTAL:
against said City In consequenor of the granting a this permit. CONSTRUCTION TAX
i � AIR HANDLING UNIT(OVER 10,000CFM)
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recel t#
material as,defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Y. MN.
Will the applicant or future Wilding occupant use equipment or devices VENILATION FAN(SINGLE BESIDE ISSUANCE DATE
which rout hazardous air contaminants as defined by the Bay Area Air -
Quality Management District? BOILER-COMP QHPOR 100,00p BTU) _�y
Yes ❑❑No \0
havcmadihehuartlousmatedahrequlm"nsunder Chapter&95of BOILER-COMP(OVER100,0001ITU)
the California Health&Safety Code,Sections 25505,25S33 and 25534. 1 _ IIIA
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.1'T. �� ��)v
responsibility to notify the occupant of the requirements mo
which at be met pis
prior to Issuance of a Certificate of Occupa ney. \1�'�_s ss� �•#.�. �'�
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY