22573 APPI_ICANTTO FELL IN INFORMATION WITHIN REL` '-WES — .SE PAI_I_ P^INIT PERk' ^`i"_V
Building Project Identification _ PERMIT NO.
Building Address:tpq-roaed Aliak
22573 Gr3
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yA4_lQ3� CITY OI DNISION
GAPPLICATION / PERMITSM*S / _NX07 BULDINGFECTR CALPLUMBiNGMCHANCAL
CATEGORY CONTROL If
Architect/Engineer. I Lic.N.
TV ELEC t0TERMd FEE ; ? r`BSi(Lp iNFQ
Address_ _ PERMITiSSUANCE EIElLICENSED CONTRACTOR'S DECLARATION
Ilumbyiffimttlut lamliceneeduMerprovleloneof Chapter9(commenc- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
I'n with Section7000)of Divisbn3o thelhsinessannlProfessionsCode,andm
rrginse is inl� ARCHITECT'S
ef(ect. 03S / y PANELS I ,^�/I��
License Clea Lk.X & Y {'I ,n
Date GO ITEC r f I 201-1000 AMPS a /a
ARCHITECT'S DECLARATION OVERIODOAMPS SQ.Ff.FLOD AREA S/SQ.Ff.
0 2 I understand my piano stall be used as public records,
tV O
Uz¢'
ct Licensed Pofessional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION
IW
D
fn SPECIAL CIRCUIT/MISC
owing aRirtnthaton731.5,Blannexempt usiness
Professions
Lite ms Law fore he aQ
FX E. ; following reason.(Renton 7811.5,BusNess and Professions Code:Any city or TEMP.METER ORPOLE INST. AUG lv j
`3p countywhichrequimapemdttommt Malwr,Impm a dem lWh,ornpair AU
q y.a anystmc mprb wibiawancea)sorequlnstheappbcantforsuchpermitb POWER DEVICES
Py O I❑LP Ufile a signed statement that he is th ensed pursuant to the provisions of the
�3q� lContractorsLicense Law(Chapter 9(no.cingwith Section 7000)ofUnit- SWIMAUNG['OOLELECTRIC A
F�O don 3 of the Business and Professions Code)orthe,he b exempt therefrom and
X the basis for the alleged exemption. Any violation of Section 70315 by any
applicant for a permit subjectsthe applicant to a civil penalty of net moethan OUTLETSSWITCHESFIXTURFS Pat]O�. )
five hundred dollars(SM. (/
n;�c NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
.. ❑I,as owner of the property,or my employees with wages r their sok
cafe 5d.7ion,Bukruethework,andtheat de:Thcture noHntende aLim I for
$ D .ale(Sec. pply Bu sinessand Prdperty Code:The lds or Impcioes Llmroe Law
g does esssuclytoan owner ofp rough who nempoymprovnthereoRand
who dceeauchworkhlmseUor[hmugh his own employees,provided that such OCC.GROUP RES.UNITS .
improvements are not Intended oroffered for eae.If,howevep thebuilding or TOTAL:
improvement issold withinomyearofcomplet ktheowner-bullderwRl have
thAJZurden of proving that he did not build or Improve for purpose of aide.). QTY, ,nILMIE4146KRAW t, - FLOOD ZONE APN
LJ L as owner of the pmperty,am exclusively contracting with licensed PERMIT ISSUANCE
mdcofess
racton to construct the project(Sec.70K Business and Probra Code:
The Contnctori License Law does not apply to an owner of property who ALTER-DRAIN A,VENT-WATER(EN
bWilds or Improves thereon, and who moment for such p -
kojects with a 7 'j'EE'TJT.IARY -
aHlTaeeor(s)licensed pursuant b the Contractor's License Law. RACY FLOW PROTECT.DEVICE t
Lt I am exempt under Sec B &P C for thin reasonOUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,CONE. SANITARY Y N_
RECE ' p
WORKMAN COMPENSATION DECLARATION pTXTURES PER.IAAF SCHOOL TAX Y N
❑I hereby affirm that I have a certificate of merest to self-inure,w a RpOf3pT p
certifcam ci Workers'Compenaatlon Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCAOUILECS PARK FEE Y N
38M,Lab Q RECEB'T p
PNey X GAS EA.SYSTEM-OVER 4(EA)
Company BUILDING DIVISION FEES
I (Certified copy b hereby fumished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
l7 JK Certified copy b filed with the city inspection division.
J— n�
E OF UEMPTION FROM WORKERS' GREASE TRAP PAID
MPENSATION INSURANCE SEWER-SANF ARY-STORM EA 200FT Date Recei t#
(Thhe completed 9 the permit infer one hundred dollars ENERGY FEEYN($1007 WATER HEATQt W/VENT/ELECTR
Ittrin mofthewwkforwMch this permit 1,ieated,I shall any ma her eo me subject to the WATER SYSTEM/TREATING
Won wso 'd PAID
OZ Appli` NEWRESIDENTIALPI.Me. SQFI. Date Recei t#
Z O NOTIC :If anal ngthfs Certo teof Exemptlon,you
should become subject to U orklan Compevatbn provisions of the Labor TOTAL:
CC N Code, tbrthwith comply with such ro vision orthb permit shall be u
CC
deemed re.-eked. py p BUILDING FEE i
CONSTRUCTION LENDING AGENCY SEISMIC FEE y'ei
Ix I hereby affirm that there is a construction lending agency for the perform- TOTAL ELECTRIC FEE
D Z anw.f the work forwhichthis permit Is heated(Sec.3097,Civ.C.)
U O Lenders Name PLUMBING FEE
LL F Lenders Address Q?Y• �' �' �" MECHANICAL FEE
O W cofertify Nate have read thin applicatlonand statethattheaboveinformation
rest.l agmeto comply with all city and county ordinances and state laws PERMIT ISSUANCE FEE$ AID'
M refining to building construction,and hereby authoress representatives of this
(_ city to enter upon the abovcmentbned property for inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify an it keep harrrdese the City of Cupertino Date Receipt#
V against llabillties,judgments,mks and expenses which may In anywayamroe AIR HANDLING UNIT(TO I0,W0 CFM) SUBTOTAL:
against said City in consequence of the granting of this permit. CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,000 CFM)
Signature of Applicant/Contractor Date EYHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture
building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recef t#
material as defined by the Cupertino Municipal Cade,Chapter 9.12,and the
Health and Safety Coda Section 25532(a)7 HEATING UNIT(OVER 100,000 BTI) TOTAL:
[3Yenfi]No
Will the applicant cefuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which smile hassrcious an contaminants as defined by the Bay Area Air - MD
Management Distdct7 BOILER-COMP QHP OR 100,"BTU)
Yea E]No
radthe hsearr ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 STL)) �/'Jy p
Iha Health&Safety Cade,Sectio r,n 25505,25533 and 25534.1 f,7 ap
and that if the building does not mmotty have a tenant,that it bmy NEWRESIDENHALMECL SQFT. MI
rsspo Qy to notify the compact of the requirements which stW mat
prix mofa ecof Orcpancy. wL�If TAA
her or autho+age to ISSUEDOX W
TOTAL:
OFFICE COPY