22248 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22248
u� 41-7 /
wnTrs ay^e one: A
Q Z'Z�/ui CITY OF CUPERTINO-BUILDING DIVISION
. Contractor's Name: Lic.N. APPLICATION I PERMIT ( r
AmhaM/Engineer. Llc.No: BUILDINGELECIRICAGI'LUMBINGMECHAMCAL CATEGORY CONTROL X
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: U 111 $11 MELH
PERMITISSUANCE �.V rVi
LICENSED CONTRACfOR'S DECLARATION
Iherebyaffirmthal l am licensed under provLNonsof Chapter 9(cornomoo APPLIANCESRESIDEMTAL ]OB DESCRfI'RON
\ 'ngwith Section 7000)of DiWslon3ofthe Busineuand Profs =sCodq and my
Lkers lCUss fomeand effect. PANES
License Clan _Contract.
ontr
Data Contactor
ARCHITECTS DECLARATION 201-IOW AMPS
q 0 CZC I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA 9/SQ.Fr.
U Licensed Professional SIGNS ELDGTRICAL N A L E D IN
t; DI OWNERexNLDERDECIARATIONK. SI'f:CIALCIRCUIT/M15C t O M P U T R
71.., DI Thereby affirm that I exempt ER the DECLARATION
License Law for the
pO following reason.(Section 7071.5,Business and Professions Code:Any city or
O Z H TEMP.METER OR POLE INST.
county ctom Pd molts unuantoconstmuirestheapmvert fors such
to //
q'� any stsigned pdennontehxt heen,also ed par amtolthe rovisi nsofpermit e POWER DEVICES
FJ O file a signed statement that he to llmnsed punuant to the tion 7M) of the
Contranor's License Law(Chapter 9(rommendngwith Sen1on70W)ofDivl-
H p SWIMMING POOL ELECTRIC
sloe 3 ofthe 8usinasand Professlora Code)orthat he b exempt therefromand VALUA�TI�ON
the basis for the alleged exemption. Any violation of Section 7MLS by any OUTLETSSWITCI-IFSEXTURES (J
65 applicant fora permit subjects the applicant to a civil penalty a not morn ban /l D
ffQQ�� five undyed dollars(SSOO.
9"' as owner of the a NEW RESIDENTIAL ELECTRSQFr, S RI
prop rty,car my employee with wages as their sole TYPE CONSTRUCTION
7� compensation,wllldothe work andthe structure la not Intended or offered for
D sale(Sec 7114,Business and Professions Code:The Contractor's Lt..Law
�$$ does not apply to an owner of property who builds or improve thereon,and OCC.GROUP RES.UMTS
who docs such work himself or through his own employees,provided that such
Improvements are not Intended or offered for sale.If,however,the building or TOTAL: .,
improvementtssoldwithinoneyearofcomplelb theowner-buederwWhave
t11X,kurdenofpmving that he did not build or improve for purpose ofsale.). QTY PLUMBING PERMIT FEE FLOODZANE APN
"L as owner of the property,am exclusively contracting with licensed nPERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code: Z V O
The Contctols License Lw does one apply to an owner rA property who ALM-DRAIN&V
builds or Improve thereon, and who contra for such p0ojects with a ENT-WATER(EA)
�•(1
co ctor(s)8cenxd pursuant to the Contractor's License law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec B &P C for this reason
• Owner Data -. DRAINS FLOOR N_
ROOF,AREA,COND. SANITARY Y_OUTS I OF. �
WORKM COMPENSATION DECLARATION RECEIPT'
❑1 hereby affirm that I have a artiflcate of consent to sail-Inco re,ora FI(TURF_S PER TRA]' , D SCHOOL TAX Y N_
artiflrste of Workers Compensation Ireuranmora end copythereof(Sec. RECEIPT'
38W,Lab C.) GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
policy 0 RECEIPT X
Cam ny GAS EA.SYSTEM-OVER 4(EM BUILDINGDIVISION FEES
[-Certified copy is heed with thahad.e
GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
Certified copy V filed with 1M city inspection division.
CERTIFICATE OF EXEMITION FROM WORKERS' GRFASETRAP PAID
COMPENSATION INSURANCE SEWER SANITARY STORM EA 2(K)FT. Date ReceI tit
Qhis section need net be completed tithe permit V(or one hundred dollars
($1 W)a1cssJ WATER HEATER W ENERGY FEE Y N
I aisn /VENT/ELECTR rtily that In the performance of the work for which this permit is
ed, —
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING n
Workers Compensation Lawsof California.Date .D(/
O Z Applicant PAID
Z D NOTICE TO APPLICANT-.If,after makingthls CertlfleateofExemptbn,you NEW RESIDENTIAL PLMB.' SQ,Fr, Date Recei t#
H � should becomesubject to the Workers'Compensation pmvmi as ofthe Labor TOTAL:
N Code,you=at forthwith comply with such pmvL^lons or this permit shall be ,
LU deeed revoked. BUILDING FEE YO
IL p CONSTRUCTION LENDING AGENCY - SEISM IC FEE r
= Z ]hereby affirm that them bI a construction lending agency forthe perfornF TOTAL ELECTRIC FEE
once of the work for which this permit b bored(Sec,3097,Civ.C.) p.f�
LL O Lender',Name PLUMBING FEE 3 O
lye endcr'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Iartilythatl have read lhhappilcatlon and statethatthe above information
4 uommo.l agree to comply with all cityand county ordinances and state laws PERMIT ISSUANCE FEE-PAID:
} U) relating to building construction,and hereby authorlve representative of
F Z city to enter upon the abovcrrentloned property for inspection purposes. ALTERORADDTOMECH.
(We)agree to sive,indemnify an d keep harmless the City of Cupemirw Date Receipt#
against liabilities,pdgmenb,caps a nd expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM)
againstsaid Citym cue of the granting a this Pamob, SUBTOTAL:
d^ ^�� AIR HANDLING UNIT(OVER IO,000CI. ) CONSTRUCTION TAX 7j.�
Sig rcof Applicant contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a pplicant or future building occupant store or ha od le hazardous HEATING UNIT 00 I W,OW BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Recel t#
I and Safety Codr•Senlon 25532(.)7 IiEATWG UMT(OVER 1W,000 BTU) TOTAL:
S
Yes I]No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emimt ha.rdoair contaminants as defined by the Bay Area Air
Quality Management DbA,kt7 BOILER-COMP(3HP OR 100,IX0 BTU) i",,I
Yes ❑❑No
ms
read the haxaNnns matenab requirements underChapter 6.95 of BOILER-COMP(OVER IW,OW BTU) JUN 111991
the California health&Safety Code,Sections 25505,25533 and 25537.I
understand that lfthe building does not currently have a tenant,that it k my NEW RESIDENTIAL MECH. SQ.I7.
responsibility to notify the occupant of the requirements which most be met as.�
prior to issuance of a Certificate of Occupancy. pi� of Cupr.tn'!
El
Owner or aulhoriud agent Date 11AA Y �fr:�6
TOTAL: ISSUEDBY: 1,4, L(L
OFFICE COPY