22624 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification {{''11 PERM ITNO.
Building Address: , VN ROAD,
D, 0) t._ - 22624
ners same: Vtl '\ �/
a0rFff S 99 CITY OF CUPERTINO-BUILDINGDIVISION ;L
�contna°taName: �1Sy�(�t��('1�7,(J/t Q1k.N ::�J APPLICATION /PERMIT [
3 '�-^'- • `+�� BUfLDINr-ELE)CTMCALPLUMBINr-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
QTY " ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: -91737717—
PERMITISSUANCE ,(� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l sen licensed under provisions of Chapor9(commenc APPITANCMRESIDENTIAL JOB DESCRIPTION
Ingwith Section 7000)of Dlvislon3ofthe Businmeand ProfewionsCode,and my ,
License Is In fife force and effect. PANELS
m .>^• � W
LlceeClass Lkec
Date Contractor
ARCHITECT5 DECLARATION 301-IODOAMPS
W lundentand myplaroshallbeused aspubllcreeards. OVERIODDAMPS SQ.FT.FLOOR AREA $/SQ.Fr.
z[j Licensed Professional SIGNS ELECTRICAL '
«6FLB° OWNER-BUILDER DECLARATION SPECIALCILCUIT/M15C
I.., � I hereby afflrmthat I am exempt fromthe Contractors License Law for the
2 fo8owingrcaeon.(Sectlw7031S,Buelneuand Profmbns Code:Mydtyar
O
=nlywhichrequimapermitto-rot c,dler,Unpmve.demolleh,orrepalr TEMP.MEfROR OLEINSI.
anyslructure prim/,its b ame,abomquirestheapplimntforsudt permit to POWER DEVICES
Q file a signed statement that he is licensed pursuant to the peon hbu of the
Contactors License law(Chapter 9(commencing with Scones M)of DIA=30 lien I ofthe Business and Profeulara Code)or that he is exempt therefromand GItJOG ELF TRIC VALUATION
Sn the bests for the alleged exemption. Any violation of Section 7031.5 by any
GA5 Pplleantforapemdt sabre lheapphi.tt.advilpewky ofnetmorethan OUTLEISSWITCI IFSF1XIlJREq'
Q ndred dollars(550 .
P .�,NEW RE9DENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n ea owner of the property,or my employees with wages as their Bole.
per cation,willdothe work andthe structure is not Intended or offered for
does sale(Sec apply to an owner
w and Property
Code:TM C Improves
Liceve law -'- _
$ whodot apply rkhi wlf thro gy sh lie playmppo idedtbatand OCC.GROUP RIS.UNITS•
wheticesaech work hlmaeBwthrwgh Meewnemploymprovldedthalsuch _
Improvements are not Intended orof(ered for sale.If,however,the build Ing or TOTAL: U.�—
improvement h sold within oneyearof completion,the owner-budderwlll have
tl rqurdrnof proving that he did not build or improve for purpose of wk.). QTY, PLUMBING PERMIT FEE FLOODZONE MN
LI L as owner of the property,am exclusively mntractlng.wlth licensed
commons to construct the project(Sec.70K Business and Professions Code: PERMIT ISSUANCE
The Contractor's License Lw does not apply to an owner of property who ALTER-DRAIN kVENTWATER(EA)
Wilde or Improves thereon,and who contracts for such Injects - -
s with a FEE SUMMARY
agBTctor(s)hamsed pursuant to the Contractors License Law. HACK FLOW PROTECT.DEVICE
I_J I am exempt under Sm. 8 k P C for thb.reaaon
SANITARY Y N
Owner Data DRAI RECEB'T R
❑ b WORKMAN COMPENSATION DECLARATIONFIXTIs" y - n SCHOOL TAX Y_. N_
I here affirm that I have a certificate of consent to se141nsure,w a /I 1 H RECEIPT I3
cemifiateofWorkeesComperuation Insurance ora wrtntsd copy thereof(Sec.
3800,Ib C.) GAS .SYS[F7d-]INC PARK FEE Y N
Pollcyk GASs RFGEfPIN -
Com any F.A.EA.D _ BUILDINGDLVISION FEES
Certfied copy is hereby ththe city
Certified copy b(lied with the cidty inspection division: IJGREASE/INDUSIRL WASTE TFRCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,IOOFF. Date ReLei t#
(TMsseatlon need not le completed lithe permit bfw one hundred dollar _
a100)er Isco.)' WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I amlythat N the perfomunwof the work forwhlch this permit is Issued,
I shall not employ any person In any manner seas to become subject to the WATER SYSTEM/TREATING
Workeri Compensation Laws of Cal fomla.Date PAID
z z Applicant - NEWRESIDENTIALPLMB. SQFT. Dale RCCCI t#
Z O NOTICE TO APPLICANT:If,after making this Certnlats of Exemption,you
_
Fshould become subject to the Workers''Compereatbn provisions o(the Labor TOTAL:
N Cade,you most forthwith comply with such provisions orthb permit shall be BU
W G deemed revoked. ..
ILDING FEE
IL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affirm that there is a coustrudfm landing agency for the perform- ELECTRIC FEE
D z anceof the work ferwhichthb permit is issued nxe 3M,Civ,CI TOTAL
C) O Lenders Name PLUMBING FEE
LL 1= Landers Address - - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW Icerillythatl have read this applkztbnaml statethatthe above ln(omutlon
1 boomed.Iagreeto comply with all dty and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} relatiW.buildi.g..mdi.,andhembyauthodmmpresenmtivmofthb
zcity to enter upon the abovcmentioned property for inspection purposes. ALTER OR ADD TO MECH.V Datil Reeei t#(We)agree to save,Indemnify an d keep harmless the City rino
of Cu Per .
against llabinties,judgments,costs and expenses which may In any way accrue AIR HANDLING(INET CFO 10,000 CPM) SUBTOTAL: ZO-2-
ag tuid City inlucoonsseeerl ee.cecele.fibe sting of this ppeemiiL�,,, AIR HANDLING 11MT(OVER I0,000CFM) CONSTRUCTION TAX
— - CONSTRUCTION TAX PAID:
Sigruiure of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) - -
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RBCCI t#
ma,rlal as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code SM ion 2553I(a)7 r HEATING UNIT(OVER 100,000 BTL7) TOTAL: Q-1�
❑Yes r1��-,f No
Wplthe appllant or luNrebo llding occupant use equipment w devices VWILATION FAN(SINGLE RESID) ISCR A'j'E
which emit hamnlous air contaminants as defimd by the Bay Area Air
Q�jalhy Management District? - BOILER-COMP OM'OR 10LD00 BTU) pOrr a��
Yn ❑No
have read the hazardous materials m
requireents under Chapter G95 of BOILER{OMP(OVFR 100,000 BTU)
the California Health k Safety Code,Sections 75505,75533 and 25534, 1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENHALMECH. SQ.IT.. Pjbss�/{/4asana4is}lk
responsibility to notify the occupant of the requirements which twist he met.
pdorto Lssuanceofa CeditkateofOnupancy. _
Owneroraulhodzedagent Date - ISSUED BY; �1` V"�kU C/—
TOTAL:
OFFICE COPY-