22468APPLICANT TO FILL IN INFORMATION WITHIN RED LINES _ USE BALLPOINT PEN ONLY
BuildingProject Identlflcatlon v. t%I— 7
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22468
ame:en
UPERTINO-BUILDING DIVISION
APPLICATION / PERMIT
BUILDINGF].EC7IUCALPLUMBINGMECIiAMCAL
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Cent rs Name: Inc.Ne
CATEGORY
CO N'ptOLNO
(OO ffOO
Arch! ed/lingineer. Lhc N.
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Address-
PERMITISSUANCE l r�
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions o(Chapter 9 (commerm.
Ing with Section 7000).! Division 3 ofthe Business and ProfesslonsCode, and my
license la In full free and effect.
License Class LIc.N
Data Conlrador
ARCHITECTS DECLARATION
I understand my plane shall be used as public records.
Licensed Professional
OWNER -BUILDER DECLARATION
I hercbyatflrm that l am exemptfcomlhe Contractor's License Lawforthe
following reason.(Sedlon 7031.5, Business and Profession,Code: Any city.,
countywhichrequlre,aper ttommtmd,alteglmpmve,demoil,h,ormpalr
any structure prior to its Issuance,alsomequfres theappllont forsuch permit to
file a signed statement that he is licensed pursuant to the provlsloru of the
Contractor's License Law (Chapter 9(commencing with Section 7 )of Divi.
slon 3 e(the Buelnna end Pro(enlaa Code) orthat he V exempt/herefromand
the basis for the alleged exemptles. Any violation o(Sedlon 7071.5 by any
appllant (ora permit subjedstheappllcant to a dvll pemltyof nd more than
p0.
flue hundred dollars of sole
1, as owner a( the property, or my em tum Is with wages r offered
.]a&cCompen.044, Busio the ness
dole (See 7044, to an ow and Protmloro Code: TM C improves License Law
and rkand the s Code: Th not intended oronse Lar
apply to an imserof mthrou property who gh his n,.pluilds y.,pr esthereoMand
dous; ratwho does
_pmveunc amrkMmaedMoroffemdfwule. lfhaw,er,thedthatsuch
Improvementsarenotintended earofodfordole. ILhower-1 theer!wilingve
improvement iewld within oMyear.fcompldloR the owner-bu0derwll have
thi,tiurden of proving that hedid'non build orlmprove for purposeo(ule.).
LJ L as owner of the property, am exclusively contracting with licensed
contractors to construct the pmjed (Sec. 7614, Business and Pro(miom Code:
The Contractor's License law don not apply to an owner of property who
Wilds, or Improves thereon, and who contracts for such p(ejeda with a
on dor(s) licensed pursuant to the Contractors License Law.
I am exempt under See B A, P C for this reason
%
APPLIANCFSRESIDENTTAL'
JOB DESCRIPTION
t
PANELS
�'
201.1000AMPS
OVER 1000 AMPS
SQ.IT. FLOOR AREA
S/SQ. Fr.
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC
..TEMP. METER OR POLE INST.
POWER DEVICES
SWIMMING POOL ELECTRIC
`N�
ETSSWITCHESFIXTURES .7t
VALUATION
NEW RESIDENTIAL ELLCTR SQ,FI,
STORIES
TYPECONSIRUCTION
�LWL
T
QTY, PLUMBING PERMITFEE
pp ((p ISSUANCE/
--
ALTER -DRAIN A VENT (GA)
OCC.GROUP
RES UNITS '
,
FLOOD TONE
APN
FEE -SUMMARY
TA Y N
RECEBT 0
BACK FIAWPROTECrD
DRAINS FLOOR, ROOF, A
FIXTURESI'PR 7RM
Owner Date
WORKMANCOMPENSATIONhave aT`SATION DECLARATION
❑T hereby ahem that I have o cedi@ate of consent to op(themc, i .
certificate of Worken'Compmuatlonlvurance orac<rtlfled copy [hereo((Sec.
3800, Lab CJ '
Policy N '
1 Y— N
RECEIPT' N
P Y N
R f M
BU CDI VISION PCIiS
CAS F.A. SYSTEM.i INC,4 OUTLETS 1
om an Y
GAS PA.SY57G1.OV I(FA)
edified copy is heed with the city
edi(Ied copy V filed with the city Iapedian division.
CERTILICATL' OPP.XEMPTION FROMWORKERS'-
COMPENSATION INSURANCE
(Thls.ed0nneednd bee.mpleted lHimpertNt hforom hundreddollan
($1I mdlf
Icertl(y yth that in the pedmm
ounof thewark forwWb
ch this permithased,
I shall not employ any person In any manner so as to become subject to the
Workers' Compensation Laws of California. Date
Applicant
NOTICE em APPLICANT: a .,kfter maide.'C. this tion pro is Exemption, you
the ply wit'C.mpemaionprovhions prude Labbe
Code,shoulyou at
Cede, d re meet (arthwlth comply with such provtsloru orchis permit shall be
scorned revoked.
CONSTRUCTION LENDING AGENCY
Horebyafflrmthatthemb a mmtrudlon lendingagenry for the parfmm
ance of the work for which this permit Is blued (Sm 3097, Clv. CJ
Lender. Name
Lenaeesnderess - -
I mellythatl have read thlsappllutionand datethatthe above Intornutlon
Iscorrect. I agree to comply with all cityand county ordinances and date laws'
relating to building construction, and hes
ereby authorize representatives; of this
ety to enter upon the above-mentioned property for Inspection purposes.
(We) agree to save, Indemnity an d kcpp harmlen the City of Cupertino
aga41b, judgments,m ander meswhich nanywayacaue
.gainm a{ue the antinge(thl.peA[R
ctor- - Date —
HAZARDOUS MATERIALS DISCLOSURE
Illtheappliantorfuture building occupant atom or handle hazardous
tergal as defined by the Cupertino Municipal Code, Chapter 9.12, and the
IFlealth and Safely Code Section 25532(x)?
❑ Yealr�No
Will the applicant eqr (urcbclldugoccupa.t..c equlproam.ndevices
which emit hazardous air contaminants a delimit by the Bay Area Air
Quality Management District? -
4Yes r1No
the ahave- read the hazar nus materials requirements under Chapter 6.95 of
lio health 6 Safety Code, Sections 25505, 25533 and 25534. 1
understand that lithe building does not currently have a tenant, that it is my
resor to issuance ofaCoheoamofoc(therequlremennwhich must be met
prior to Lauance ofa Ccrtllcetc ofOFcvpanry. �
'GREASE/INDUSIRI. WASTE INTERCEPTOR
PLANCHECK FEE
r7 '/ , 41N_wy�fy
PAID I�C` (
Date Rete{ t#
GREASE TRAP
SEWER -SANITARY -STORM EA. 200FT.
�
WATER HEATER W/VENT/ELECTR -
ENERGYFEE Y N
gyp N—
�•%. J' /' (7t
PAID Ib
Date Remi t#
WATER SYSTEM/TREATING
NEW RESIDENTIAL PLMB. SQFT.
-
TOTAL:
BUILDING
TO �.
SEISMIC FEE
ELECTRIC FL•E
QTY. MECHANICAL PERMIT FEE
PLUMBING FEE
MECHANICAL FEE
PERMITISSUANCE
FEES PAID:
111
ALTFRORADDTOMECH.
2 AIR HANDLING UNIT (TO 10,000CFM)
Date Recel t#
SUBTOTAL'
HANDLING UMT(OVER 10,000CIM �.
CONSTRUCTION TAXhcant/Con
IXIIAlJS'T FIOOD (W/DI1CT) �.:.
CONSTRUCTION TAX PAID:
,
HEATING UNIT (TO 100,000 BTU)
Date- Recet t#
HEATING UNIT (OVER 100,000 BTU)
TOTAL:
VENDGTIONrAN(SINGLE RFSID)
ISSUANCE DATE
fry p
P A
A j
AUG .N a ���
ISSUFDBY
BOILER -COMP DHPOR 100,000 BTU)
BOILER-COMP(OVER 100,000 BTU)
NEWRMDENHALMECH. SQ.FT. -
�
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01
Owner or authorized agent Data
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OFFICE COPY