22513 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ed Identification PERMIT NO.
Building Address: 2 2 513
D r
assn: / one: q
r CITY OF CUPERTINO-BUILDING DIVISION �2 ^
APPLICATION / PERMIT
BUfLDING-ELECTRICALPLUMBINC-MECHAMCAL CATEGORY CON'IROLa
rchited/Engineer.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby
ectionaffirm that lamlken3ofthe under uMmvLandP fChapter
ssims9de,and m APPLIANCESRESIDEMUL' J08 DESCRIPTION
lnenseISection 7000)oforce and
(the8usinessand Pmlessiona Code,and my r--s
Li..lsla full force and d(ed. PANELS S Date
Contractor
•J
Date CHITactor
ARCHITECTSDECLARATION OVER
AMPS
]understand my plea shallW used as public records. OVER 1000 AMPS SQ.FC.FLOOR AREA 5/SQ.Ff.
}e L Licensed Professional SIGNS ELECTRICAL g L E D f
G<< OWNER-BUILDER DECLARATION
G Fn ��
Iherebyaffirm that lamexempt fromtheContmetor'a Licens SPECULCIlTCUT/MISC
Lewforthe (� /1
70pF� fo0awing mason.(Section 7ml5,Buelnese and Pmfealans Code:Any dtyor TEMP.MEfFRORPOLEINSF. M\V/�
TE
county which requires a permit tocontroq alter,bnprove,demolish,m ospair
qq anystmcture priorto its Issuance,also requlresthe applicant forsuch permit to POWER DEVICES rE
l5 file a signed statement that he is licensed pursuant to the provisions of the
3c: Contractors License Law(Chspter9(comer¢ndng with Section 7000)of DIA- SWUvWNG POOL ELECTRIC VALUATION
O< slon3ofthe Buslnnaand Profession Code)orthathebesem therefmmand
yi^) the basis for the alleged exemption. Any violation of Section 78)1.5 by any
OUTLETSSWITCHESFIXTURFS
EW ape hundred do[)..($50jede the applicant to civil penalty of not morcthan
five hundred owner
of he pr). NEW RESIDENTIAL ELECTR SQ.FT.
� ❑I,a owner of the property,or rtry employee with wages as their sok STORIES TYPECONSTRUCTION
C compensation,will do the work.and the structure is not Intended or offend for
5 n saleISee 7094,Business and I'mfesdom Code:The Contractors Llcenm law
(js$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RES.UNITS
EE whodoessuchworkhimslforthrough hisown employees,provided thatsuch
Improvements arc not Intended oroffered break.If,however,thebuilding or TOTAL:
Improvement bsoldwithin oneyearofcompletion,the owner-buRderwill have
ft-tIurden of proving that he did not Wild or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE APN
L_(L as owner of the property,am exclusively 00mracung with Ilmnxed
contractors to consM
construct the proj (Sec.7044,Business Profession Code ProfessioCode: I PERMIT ISSUANCE W
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improves thereon,and who contracts for such pi jects with a
on,lE[dor(s)licensed pursuant to the Contractor's Limis Law. BAIX FTAWPRIyfECT.DEVICE FEE SUMMARY
11 am exempt under Sec B&P C for this reOUTSIDE FEES
Owner Date awn DRAINS FLOOR,ROOF,AREA,COND. SANITARY Y_ N C1 'C
WORKMAN COMPENSATION DECLARATION RECEIPTp—T J��
FIE hereby affirm that I have a cortigate of consent to self-insure,or a FTXTVRFS PER TRAP SCIiOOL TAX RFGETPT M
coatflateofWotk.'Compe.tlonl..ra ora certified ropythereof6ce. GAS EA.SYSD]vf-1 INCA OUTLETS PARR FEE Y N
3800,Lab C.) — RF-CEB'T p
Policy p GAS m EAC. ..SYSTF7.1-0VER d(FA) BUILDING DIVISION FEES
Coany
-erttfiea copy is hercbytthe cid. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑ lf Certed copy b filed withh the city inspection division.
CERTIFICATE OFO(EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.ZX)FT. Date RCmI t#
(Thissectlon rased out W completed lithe permit bfm one hundred dollars
($10(Eorless.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhlch this permit is Iswed,
I shall not employ any person In any manner soasto berme subject to the WATER SYSIEM/TREATING
Workers'Compenvtionlawso/Ulifornk.Date PAID
OZ Applicant NEW RESIDENTIAL PLMB. SQFT. Date Remi t#
Z O NOTICETOAPPLICANT:ILaRer making thisCertifiateof Exemption,you
P W should WcoRlt subjsd to the Workers'Compermatlon provialon ofthe Labor ,/_ -fin a,.yy TOTAL:
Code,you=at forthwith comply with such pruvbloru orthb permit shall be C�t�9`/�!/ (�✓ BUILDING FEE
W j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency for the perform r7x /Y1 ELECTRIC FEE
M Zance ofthe work forwhlch this permit b based(Sec.3097,Civ.C.) TOTAL:
OO IeMer'sName PLUMBING FEE t 1,CC)
F Lender's Address QTY. MECHANICAL PERMIT FEE
ly MECHANICAL FEE
[;correct. to complywith all city m ty and county ordlnanand state laws PERMIT LSSUAKCE FEES PAID:
r 1 IL relatingtobuildingronwdlon,and rcbyauthorlurepresntativesofthis
F 4.1.at.idtt
upo eabove-menti property for Wpecion purposes. ALTER OR ADD TO MECH.Z e vie lndemrd rad ph eatheClryo(CupedinoDate Receipt#
O ll greents, an pen whkhmayIr"y ya , SUBTOTAL:
ty coo
s this perm)f9.t� AIRHANDLINC UMT(OVER IO,000CIM) CONSTRUCTION TAX
A Ban Contractor Dar " EXHAUSTHOODIW/DICT) CONSTRUCTION TAX PAID:
H RDOUS MATERIALS DISCLOSURE
a nt orhiWm building ompier store or handle hazardous HEATING UMT(T0103,0008TU) Date Recef I#e Ined by the Cupertino Municipal Code,Chapter 9.12,and the
I leallh and Safety Code Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Fly. , MN"
Will the a ppliant orfuture building occupant use equipment or devices VEMTLATION PAN(SINGLE RESID) ISSUANCE DATE
which emit haanlous air contaminants as defined by the Bay Area Air
Quality Mangcmort District? BOILER-COMP DEEP OR 100,CM BTU
4Yes ❑❑No
havemadthe haurdousmaterials reqummentsunderChapler6.95of BOILER.COMP(OVE9100,"BTU
( the Celifernla l ialth&Safety Code,Sections 25505,25533 and 25539.1
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT ry
responsibility,to notify the occupant of the requirements which must W met V
prior to issuance Dfa Certificate of0 pancy. e
Owner or authorlud agent Date TOTAL: ISSUED BY:
OFFICE COPY