22493 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY.
Building Protect Identification - - PERMIT NO.
BuildingId3 e 22493
ereanrv:' A
ca-.L,', S'Sb'�S7-LI " CITY OFCUPERTINO-BUILDING DIVISION
Contra`T°"N.cou vs 4.s LSer+ Lic No APPLICATION / PERMIT
.. I'ArcMtect/ling/neer. -BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CO
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QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMIT ISSUANCE ca) ❑ " ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby am.that I am licensed under provislons of Chapter 9(mmmenc- APPLIANCES-RESIDENTIAL JOB�DES�C—R+R'f{ON
Ing with Section 7000)of Division 3 ofthe Buslnesu.d PmfeselonsCode,and my �5 l\-1aa�Y HDE _
license Is is(sail(rpcp and effect /q 1 PANELS 1 _
It . Class Lk.X
'D ContraRor_
ARCHITECTS DECLARATION 701-IMO AMPS
O I understand my plana shall be used as public records. OVER 1000 AMPS SQ.FP.FLOOR AREA $/SQ.FC. .
Licensed Professional SIGNS ELECTRICAL gt8�
OWNER-BUILDER DECLARATION SPECIAL CRRCUIT/MISC aA tt, VVV
OO � I herebyafflrtnthat I arrexempt from the Contractor's License Law for the _ '`tlll
2 p
following reasequirm.(Section
pe 70313,Business and Pmprove, Code:Any city or Ta1B METER OR POLE INST. f I� 11�
t~4. d 'wuntywhlch requlresa permkroconutruct;alter,Improve,demolish,orrepair t(7y
anystructom prior in Its issuence,also requires the applicant for such permit to POWER DEVICES
O file a signed statement that he Is licensed pursuant to the provisbv of the /� 1' j
(-. ER
Contactors License Law(Chapter 9(commencing with Section 7000)of Divi- `=' Y ' �—
,^�O:} elon3.fthe Busine...dProfembmCode)orthathelsemmptthemimmand SWIMMING POOL ELECTRIC � - ALUA'1'IpN
�5�p*' •3 .the basis for the alleged exemption. Any violation of Section 70315 by any
p� aPpBant for a permit subjects the applicant to a civil penalty of not morethan OUTLETSSWITCHESFIXIURES l [/ T
five hundred dollars;($500).
.n ❑I,as owner of the roe NEW RESIDENTIAL ELECTR SQ.FI, STORIES TYPE CONSTRUCTION
property,ky,or my employee with wages a there sole
'compensation,7'On,Business workendthestroctureisnotintended oroffered for
q sale(Sec.apply
to show and f property
Code:The Contactors License Law
does$ whodot apply roan awnerofpropeky who nem impronm and OCCGROUP RFS.UNITS
whoovronees is ork eranhlmsendedoroughwi ow le.if osweprovidedthatsuch
improvementsaretwtintendneyearfBredplatin theowevegilder Ili have TOTpL; 1
Improvement[scold withinoneyearofcompletioMthe mvnervbu0derw111 have
t4LLmrden of proving that he did cwt build or Improve for purpose of sale.). QTy. PLUMBING PERMIT FEE FLOOD PANE APN
LJL as owner of the property,am exclusively contracting with Ikenaed pptM1T ISSUANCECyt
contractors to roretruct the project(Sm.764.Business and Professions Code:
The Contactors License Law does not apply to an owner of property who ALTER FEE SUMMARY
-DRAIN&VENT-WATER(F.N
c
Wilds or Improv.thereon, and who contracts for such p-ojects wall,a
,Il[�actor(.)licend pu.uanf to the Cont d&.License Law.LJ seI am exempt under Sec. B k P C for this reason BACK FLOW PROTECT.DEVICE
Owner DRAINS.FLOOR,ROOF,AREA,COND, SANITARY. Y N—
Date.•. WORKMAN COMPENSATION DECLARATION RECEIPTX '
FD(TURES PER TRAP SCI{ODL TAX Y N.
❑I hereby affirm that I have a lmum to of consent d spythmre,ora RECEIPT X
reki,abC.Workeri Compematlonlmunnce ora ceki(Ied cagy thenrof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKME Y N_
3E00,Lab C.)
PollcyX GAS FA.SYSFEM-OVER4(EA) RECEBUILDING DI VISION FEES '
e lied copy le hereby furnished. . GREASE/1NDUSTRL WASTE INTERCEPTOR
PLANCHECK FEE
' kUicd copy hi filed with the cityirupectlon division. .a ,
CERTIHCATE OF EXEMPTION FROM WORKERS' GREASE TRAP'' PAID—7
�3Zn If.IS-
COMPENSATION INSURANCE SEWER-SANITARYSTORMEA 700F1'. Date=� ReceI t#
(13)m lactlon need not be completed if the permit le forone hundred dollars
($t I comlem.) WATER HEATER W/VRNT/RLECTR ENERGYFEE Y, N
]cekl(ythat laths periormance a(the work(ora hpWepeonit lsbaed, —
I dull not employ anj person In any man w t 6 come sub' to the WATER SYSTEM/TREATING
Work en'Com Laws lifo )I�Da . PAID
0 Z AppllcantY �S.. NEW RESIDENTIAL I'LMB. Date Revel t#
Z O NOTICE O MANE:B,after making a of Exemption,you —c'RJ'T
Nshould become subject to the Workers'Co mation provisions ofthe Labor - TOTA
— Code,you=at forthwith comply with au provislors orthis permit shall be BUIL G .0
deemed revoked.
LU
G CONSTRUCTION LENDING AGENCY - SEISMIC FEE
Thereby affirmthat there le a construction lending agency forthe perform TOTAL: ELECTRIC FE' -,
O armoftheworkfor which this permit is issued(Sec.3097,C1v.C.)
V _ lenders Name PLUMBING FEE
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE ZFEESPAID:
ICAL FEE
.0 W I certify that l have read this application and state that the also veinformation
umrrect.I agreeto complywith all city and county ordinances and nate laws PERMIT ISSUANCE�. C relating to building construction,and hereby authorize representatives ofthi.W city to enter upon the above-mentioned property fors ton purposes. ALTER OR ADD TO MECH.(We)agree to save,.indemnify an d keep har Ih City of Cupertino Reeei #against liabilities,judgments,mrtsand expense w sh yman wa amm. AIR HANDLING UNIT ITO 10,000 CFM)y y 'SUBTOT L:against said Ci consequence of the grant) !this emit. AIR HANDLING UMT(OVER 10,000 CFM) CTION TAX
g a repliant/Contractor Data E%HAUB'IHOOD(W/DUCT) CONSTRUCTION TAX ID:
NAZARDOUSMATER LS DISCLOSURE
-
Willtheapplicantorfuturebuilding pantatme or hind Is hazardous HEATING UNIT CTO 100,000 BID)
terial as defined by the Cupertino Municipal Code,Chapter 9.17,and the Date Recel
Health and Safety Cod a Section 75537(a)? _ HEATING UNIT(OVER 100,000 BTU), TOTAL
❑ TOTAL:In No '
Will the applicant or future Wllding occupant use equipment or devices VENITLATTON FAN(SINGLE REM) - ISSUANCE DATE
which emit hawrdous air contaminants as defined by the Bay Area Air -
ality Management District? BOILER-COMP DEP OR 100,000 BTI)
Yes (1��No
haveread the hazardous Code,Section 25505,25533 aChapte4.I of BOILER-COMP(OVIR 1fA,000 BTU) ?L��
the understa
ndnia
ealth if the building
Code, otcursntlyh have
a tenannd t,
]
understand thatn notify
the occupant
of the require encs tenant,that blsmy • NEW RESIDENTIAL MECH, SQ.FI' �
responsibilityor tuce notifytheoatc of of the requirements which must be me[ SEPI
prior to issuance ofd Certificate of Occupancy. (`' 1 3
Owner or authorized agent Data ISSUED 0�].tCfYY
TOTAL:
OFFICE COPY