22495 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Prn ect Identification PERMIT NO.
Building Adtlress: � - . 22495.
-1863 C_Il
nero .—. I Phone: - A
ttx.x TMAc �'�-�SYtI CITY OF CUPERTINO-BUILDING DIVISION
Contractor'.Named QQAPPLICATION / PERMIT '
�
rchitect/Engineer. ya�=•9NGo. BUILDINr EaMTMCALPLUMBING-MECHANICAL CATEGORY COW�/
i9=2
Llc.No:
S, QTY ELECTRIC PERMIT - FEE BUILDING PERMIT INFO
Addreac
PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
Thereby affirm 7DOO)oi am Ecrn3oftheusinmvWoea(Chapter
ssiona9(coandmy APPEANCES-RESIDENTIAL JOB DESC ON
Ingwith SecWn7000)ofDlWaivn3ofthe Businessand Pro(esaloneCode,and my -
Ilcenee lain E( 'e a d effect. - 1 PANELS
Lfi
License ea..V' •�! Contra,.
D Contraco �/f/� t
ARCHITECT ECLARATION f 201-1000 AMPS
{❑S aO! I understand my plane shall he used as public records. OVER1000AMPS SQ,FI,FLOOR AREA $/SQ.Fp,
E Licensed Pro(esslonal SIGNS ELECTRICAL �f 1` �s
�6 ffiOWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC —1 r
1herebyarm Nat I am exempt fromthe Contractors License Law for the
rOR-, following recon.(Section 7031.5,Business and Professions Code:Any city or L
uwhich requires a permit to construct alter,Improve,demolish,or repair TEMP.METER OR POLE INST.
county'� anystruclure prior to its Issuance,also requires the applicant for such permit to
file a signed statement that,he is licensed pursuant to the provisions of the POWER DEVICES
Contractor's License Law
th Section 7000)of Divi-
d nlolthe BuI eu"dProfmWer r Cole(commencing i
rlhathei exec pt,loe fromand —SWIMMING POOL ELECTRIC - VALUATION
F+Eb S the Wei.for the alleged exemption. Any violation of Section 70315 by anyx �za L (no
subjects Neappllcanttoa civil penally o(not more thani�o OUTLETS-SWITCHES-FIXTURES 7� V4LL
five hundred dollars(S500).
�n ❑I,is owner of the property, NEW RESIDENTIAL ELECTR SQjrL JCYPE CONSTRUCTION
p petty,or my employees with as their sole I
y4 compensation,wilidothe w.rk.cdthe stm=w isnot intended or offered for
P O sale(Sec.7044,Business and Professions Code:The Contractors License Law
Nj R does nM apply to an owner of property who builds or improves thereon,and R RESUNITS
who does euchworkhlmseHarthrough Nsownemployees,providedthatmch ^ �/
improvements are not intended orof(ered forsale.If,however,thebuilding or T G� 7
improvementlssoldwithinoneyearofcompletion,theowner-bu0derwBlhave 7 / Z -
'tlULas ower ing of the prodid perty,am
excluild orimprovefor actingpurpose h licensed
QTy, PLUMBING PERMIT FEE RGOD ZONE- APN
U I,as owner of the properly,am.7044,exclusively contracting with Is Code' ' PERMIT ISSUANCE �l FY 1
contractors to co tmdslim the project(Beet apply
Business and of prolene Code: 'r-'1
The Contractor's es the law does who
apply torn owner W property who ALTER-DRAIN&VENT-WATER(EAI
Wilds to improves thereon,and who tmemes ice such pRojem with a FEE SUMMARY
copt-(acmexe pt under ant SmNthe Contractor's License Law. BACK FLOW PROTECT.DEVICE
t I am exempt under Sea B &P C for this reason
DRAINS-FLOOR.ROOF,AREA,COND. SANITARY Y N
Owner Dare r
WORKMAN COMPENSATION DECLARATION RECEIPT OFET.URES.PER TRAP SCHOOLTAX Y _ N ^
❑I hereby aHlrm that 1 have a certificate of consent to eel(-Nwre,ora s�4•��s RECEIPT'X
certificeMo(Workers'Comperuatlon Insurance oracerti(kd copythereo((Sec. GAS-EA.SYSTEM-1 INCA OUmmh sW PARK FEE Y N
Polis Lab CJ
Policy X RECEE'T X
Co GAS EA.9YSTEM-OVER4(EA) BUILDING DIVISION FEES_
milonls herebyth the cited.y
GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy ls filed with the sty Ircepeclon division. _
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP
COMPENSATION INSURANCE SEWER-SANITARY-S]ORM EA.200FT. Date -ate !— Recef t#
(Thissecilon need not be completed If the permit ls foroe hundred dollars
(5100).,1..) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N b�,.49
I certifythat in the performance of the work forwhlch this permit is Issued, —
I shall not employ any person In any mange as t mpie eubj ct to the WATER SYS1,F7v1/,T,REA.I,[NG
Workere'Compen we off Calif Z r1 7 PAID
O Z . Applicant Date Recei t#
Z 0 NOTICE TO APPLICANT:If,after makl this Ceriicateof Exemption,you NEW RESIDENTIAL ELMS, SQ1-7
Hshould become evb*d to the Workers'Compensation provisions of the Labor - TOTAL: r
N Code,you=at forthwith comply with such provWone or this permit shall be BUILDING FE /
deemed revoked. -
aC CONSTRUCTION LENDING AGENCY $$[SM C FEE
[hereby affirm that there Is corutmclon lending agency for the perform- LECTRIC FE
� Zanes.(theworklorwhlchthlspermitlstssued(Sec.3097,CIv.C.) TOTAL: ' `
U O Lander'sName - PLUMBING FEE'
LL — Lenders Addreea QTY, MECHANICAL PERMIT FEE MECHANICAL FEE a
O W IcerU/ythatl haveread thisapplimtlonand etatethattheabove Information ,q
CL lerorrec.l agreeto comply with all city and county ordinances and state law a PERMITISSUANCE LAW FEES PAID
�. relating to building conetrucion,and herebyauthorize representativesoftMs s'CV
Z city to enter upon the above-mentioned property Inspection purposes. \ ALTER OR ADD TO MECH. Date R2CeI [#
— (We)agree to save,Indemnify an d keep h ss the City of Cupertino
against liabilities,pdgments,"sand expen ew kh may In anyweyacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTO L'
a ste 1 In canaequence of the gra n [hie pe
' AIR HANDLINGUNIT(OVER Io,000CFM) CONSTRUCTION TAX
ign'afumof Applicant/Contractor Z, Date EXHAUST HOOD CW/DUCH CONSTRUCTION TAX, ID:
HAZARDOUS MATERIALS DISCLOSURTI _
Will theappllcant or future building occupant store or handle hazardous HEATINGUNITHO100,000BT'U) / . Date Receipt
material as defined by the Cupertino Municipal Code,Chapter 9.I2,and the
Health and Safety Code Section 25532(a)7 FIEATING DMT(DVER 100,000 BTU) TOTAL. L
❑ Yes No
Will the applicant orfuNre building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) .. ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air "
Quality Management District? BOILER-CAMP CHIP OR 100,000 BTU) '
4 Yes [No 10R�
have read the bazar ossa materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) R'�
the Glifomls Health&Safety Code,Sections 25505,25533 and 25534.I q ✓
It7�yo
understand that if the building does not currently have a tenant that it is my NEWRESIDFNTIALMECH. 'SQ.FI SEPT �
responsibility to notify the occupant of the requirements which must be met
prior to Issuance of a Certificate o(Occvpanry. - �wXE•Q}. _
Owner or authodacd agent - pate
TOTAL: ISSUGDBI
I
OFFICE COPY