22616J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
/
Building Project identification PERMIT NO.
Building Address:
22616
wners ante: nee.
AA
IE
CITY OF CUPERTINO-BUILDING DIVISION
Contractors Name: Lic No: APPLICATION / PERMIT �� I
�� �. �� s�rc eio_
Amhitxt/Isgineen Lk.No:y
BUILDING-Fl.ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL#
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: ( PERMTISSUANCE �� ❑ ❑ El
CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provinces of Chapler9(commene APPUANCESRESIDENTIAL JOB DESCRIPTION
S¢ ion7000)of DMsion3oufthe Businessand PmfemimsCode,and my
Ltense"Ch® V and ic.# r66 PANELS Q 1
Date KC ntnRort I 6. ] V C--a--�.
ARCHITECTSDECLARATION 701-IODO AMPS
q�v0470 I understand my plans shall be used as public records. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
fr+�� Licensed Prole.1mol SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M75C
Ihereby.M.that l am exempt from the Contractor's License law for the
DOF following reason.(Section 7MI5,Business and Profanbns CAny y city or (A(p.METER OR POLE INSf.
F,Z cmntywhichrequi apert tmroretmd,Oter,"mpm ,demolbh,ormpalr
a anystm=mpdortoiul mance,al mquimstheappBantforsuchper tto ({EWER DEVICES
V file a signed statement that he Is licensed pursuant to the providers of the
COs (A " esa (Chapter
(commencing
owith
Section
sIon3oftheBudnndPrem"omC rhahe�emmptthemfmmand SWIMMINGPOOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUILETSSWHOHESFlXTURES
apph.et fora permit subjects the applicant to a civil penalty of not more than
e. five hundred dollars($500).7< NEW RESIDENTIAL ELECTR❑1,as owner of the property,or my employees with wages as their sole SQFr. STOWES TYPECONSTRUCTION
compensation,will clothe work and thestmcture Is net intended or offered for
5 O sale(Sec 704q Business and Pmfessiov Ce:The Cmuracors Llcerse law
s$ does not apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work hlmselforthrough his own employees,provided that such
Improvements arc not Intended or Df Bred for sale.K however,thebullding or TOTAL: 3�l
Improvement b sold within oneyearofcompldion,the owner-bulMer will have
t)c�urden of proving that he did sot build or improve for purpose ofsale.). QT . PLUMBING PERMIT FEE F(pp zONNp XpN
"I,as owner of the property,am exclusively mntrading with licensed PERMIT ISSUANCE
contractors to construct the project(See 7014 Business and Professions Code:
The Contractors License Law aces not apply to aet owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon,and who contracts for such ptajecs with a
,lB�adorts)Ikenvdpumantwthe Contndor'sLlcenw Law.
ondo
am exempt under Sec B &P C for this reason BACK FLOW PROTECT,DEVICE FEE SUMMARY
Owner e DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEB'T I
❑1 hereby affirm that I have a certlfiate of consent to self-inure,or a FIXTURE4 PER TRAP SCAOOLTAX Y_ N_
certiBateof Workers'Compensation Imunmuma certBied copy thereof(Sec. RECEB'T N
3$00,lab C.) CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Polity# RECEB'f M
Com any GAS FA.SYSTEM-OVER 4IRA) BUILDINGDI VISION FEES
�Cenlfed copy is hereby furnished. GRPASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
�jtCeni(ied copy b filed with theecity
Inspection dlvlslon.ty
�'� CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(This section need set be crmelemA If the permit is(atone hundred dollar SEWER-SANITARY-STORM EA.200FT, Date Rccei t#
($100)mfy that WATER HEATER W/VENT/ELBCTR ENERGY FEE Y N—
I
thatinthe person
ftmanner for which Wapermitbtimed,
I shall not employ any pereon in any manner m az t9-beSQnp sybje to the —
O Workers Comp naafis wsof Call( 6. Date_ F—Y WATER SYSTEM/TREATING PAID
Applicant fir, ...ei
_Z 0 N077CE TO N'PLICANT:B,after making this CertRiateof Exemption,you NEW RESIDENTIAL PLMB.__SQ}L Date Remi t#
should become'subpet to the Workers Compcmatbn provbiom of the Labor TOTAL:
~ fA Code,you mast forthwith comply with such provistme,or this permit shall be
� j devoted revoked.
W c DULL IN FEE
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Thereby affirm is thiaermtmctlonct(Secgagenry for the perforrry ELECTRIC FEE Q
Z ante of the work for which this permit b issued(Sec,3097,Cie.C.) TOTAL:
U O Lender'shame PLUMBING FEE
U.0 L eaters nacrea QTY. MECHANICAL PERMIT FEE
O W Ianifythatl havereadtheappliatlonand rtatethattheabovr ln(ormatlon MECHANICAL FEE
a bcorreet.I agree to comply with all city and countyerdinascesand date laws PERMIT ISSUANCE FEES PAID:
N relating to building rovtmdlon,and hereby authorize rcprexntativesrfthis
H z city to enter upon the above.mentiomd property for inspection purposes. ALTTRORADDTOMECH.
U — (We)agree to save,Indemnity an d keep harmlea the City rf C.penlno Date Receipt#
a Sabot lhbJities,judgments,costs and expenses which may In any way accrue AIR HA NDLING UNIT I g0p0 CFM) SUBTOTAL• ?:Z-
-
MR
met said City in consequence of the gra sting of this permit
AIR HANDLING UNIT(OV M I O,Wo CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) CONSTRUCTIONTAXPAID:
HAZARDOUS MATERIALS DISCLOSURE
Willtheappl"ant or fewer building occupant store orhandle hazardous HEATINGUNIT(TO IOgWOBTV)
maerialaseleRned by the Cupertino Municipal Code,Chapter 9.1$and the Date Reeei t#
Ekalth and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU)
F1
Yes . r]No TOTAL:
Willtheappl"ant or futureboildingaccupantueeequipmenl ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamimnta as dented by the Bay Area Air
QualityManagementDisWct7 BO[LER-COMP DEE'OR 100,010 BTU) PAR
4Yes g No
havercadtbehazar`Tousmateriabrequime ntsunderChapler6.95of BO LER-CUMP OVE]i 700,000 BTU) n(I�
the California Flelith&Safety Code,Sedlore 25505,]5573 and 75530. I
understand that if the Wilding don net currently have tenant that ltkmy NEW RESIDENTIAL MECH. SQ.FT. N V
rapoosibllity to notify the occupant of erequimme.ts which must bemet
pr' ,D' of a Cenllka .a Ty
.4,,neyo,authomma agent Data
TOTAL: ISSUEDBY: V� ��� Il (T
OFFICE COPY