22421 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proud Identification PEA.MIT NO.
Building Address: 22421
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wnerf`a/` ' one: q
Swf� N00 o2S3-va6p0 CITY OFCUPERTINO-BUILDING DIVISION �q
Contractor' Lic.No: APPLICATION / PERMIT
D 1 1\ (..��S7(LU[��j Q I V BUILDING-ELECTRICAGPLUMBING-MECHAMCAL CATEGORY CONTROL p
ft Architect Fn sem Lic.No:
��-1L) /� EG QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: (/ PERMIT ISSUANCE 2
LICENSED CONTRACTOR'S DECLARATION �•
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'
4
Ihy affirmlhlinunder pmvinsofCha (marnmenc- A'PLIANCE4RESIDENTIAL ]OB DESCRR'DON
IngwlthSctonr)ofDion3oftheBusuandProfssosCode,and my
full foe and effLk,ectPANELS
Date ComNnctor UPT0200ANIPS
ARCHITECT'S DECLARATION 70t-1000 AMPS
N
N7 I understand my plum shall bco
Is,used as public records. OVER 1080 AMPS SQ.R.FLOO EA
�O SIGNS ELECTRICAL ALE
j Licensed Pmfessbnsl
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC I� A
I herebyaffirm that lam exemptfrom the Contractor's License law for the 'V,
7 0...p�p following reawn.(Section TOES,8uslness and Professlmne Code:Any atyor ?EMC METER OR POLE INS!.
TIE
Fzii-M cauntywhlchrequlresapemdttowmtmMt ter, pmve,demo h,orrepalr / / /
99�Q anystm=mprtortoitsdmance,aLwrequlmtheappb=tfomchper tto POWER DEVICES DAT 1!
O file a signed statement that he is licensed pursuant to the provislom of the
Oaf Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
30 sion3ofthe Business and ProfessionsCode)orthat he is exem therefromand VALUATION
16 X the basis for the alleged exemption. Any violation of Section 70715 by an OUILETSSWITCHESHXTURES 1��� S Q Q O
applicant fora permit subjectsthe applicant to a civil penalty of not more than l \ oo
five hundred dollars($500). NEWRESIDENTIALELECTR
❑ SQ.FT. STORIES TYPE CONSTRUCTION
I,as owerty,
owner of the prop ,or my employee with wag.as their w
mmpensatlon,willdo the work and thestmcturc is not Intended or Bred or
X00 sale(Sec.7064,Buairewand Pmf.knsCode:The ConhmWofs
A2 does not apply to an owner of property who builds or ren d
�^ whodo.such work himself or through hisown employees,p d t t OCC.CROUP RES.UNITS
improvementsarc not intended oro(fered(orsale.If,howevegt Edi TOTAL:
Improvement bsoldwllhinoneyearmcornplellon,tio, nem-bu rout
th rden ofpmving that he did not Wild or impmve for pia v .).e FEE FLOOD ZONE APN
�1,as owner of the property,am exclusively coo or II sed PERMIT ISSUANCE
contracmnto co.muct the project(Sec 7014,Bush, and 1 Cod .tl
Cot
The Contractors License Law does not apply to an owner of perry wh
Wilds or improves thereon,and who contracts for such pkojecb with a ALTER-DRAIN&VENT-WATER(EM
c%q.ctor(a lke
nsed pursuant to the Contractor'.LI...Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
UI am exempt under Sec. B&P C for this reasonOUTS I DE FEES
DRAINS FLooiR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION / FIXTURES-PER TRAP "� SCHOOL TAX Y_ N_
711 hereby affirm that I have a¢ self-insure,
nificate of consent to or a l RECEIPT M
P omiflcate of Workeri Compensatton Insurance ora certified copy thercof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3g00.Pab CJ
Policy N RECEIPT N
Com a GAS FA.SYSIPM-OVER4(EM BUILDING DI VIS ION FE ES
enlRe
dd copy V hereby fumished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified copy is filed with the city Inspection division.
CERTIFICATE OF EXEM PTION FROM WOR KERS' GREASE TRAP PAID
700FT
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA RCC21 t#
(rids section need not be completed If the permit b for one hundred dollars Date
WATER HFATERW/VENT/M TR ENERGYFEE Y_ N_
I certify that In the performance of the work forwhlch this permit is Lured,
I shall not employ any pelon In any manner so.to become Object to the WATER SYSTEM/TREATING
Workeri Compensation Law.of Gllfomla.Dale PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recel I#
Z O NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you
HN should become,subject to the Workers'Compensation provisions ofthe Labor TOTAL:
� j Code,you must forthwith comply with such provisions or this permit shall be BUILDING ICO
deemed naked.
IL — CONSTRUCTION LENDING AGENCY SEISMIC FEE a�
a Iherebyaffirmthatthem Lsaconstruction hadingagencyfortheperform C
7 Z arce of the work for which this permit b TOTAL: ELETRIC FEE OG
Issued(Sm.3097,CIv.C.) \ PLUMBING EEE
02 loaders Name
LL h- Lenders Addms QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I curtly that l luvemadthb application and statethatthe above Information r�
u correct.Iagree to comply withal)atyand countyordinanmand state laws PERMIT MANCE FEES PAID:
>_ N relating to building construction,and hereby authorixe representatives of this 1
f. Z aty to enter a Pon the above-mentioned property for Wpectlon purposes. ` ALTERORADDTOMECH. l� Date Receipt#
(We)agree to save,Ind emnlfy an d keep harmless the City of Cu pen Ino O AIR[1ANDLINC UNIT(T010,000 CFM)against liabilities,I.dgmmt.,costs.rad expenses which may In any way accrue SUBTOTAL:
aga Inst said Cllyin Keane of the granting d this permit.
AIR IiANDWNC UNIT(OVER 10,00CISH) CONSTRUCTION TAX
ature of Appllant/Contractor - Date EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle luardow HEATING UNIT(TO 10,00 BTU) Date Receipt#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
I lealth and Safety Code Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes InNo Will the applicant or future building omupart use ryulpment or devices VEN"DLATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous it contaMants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OIIPOR 100,000 BTU)
Y. M No
Tuve read the hazar ous materials requirements under Chapter 6.95 of BOILER-COMP(OVER10,000 BTU)
the Californiatand Health building Code,Section 75505,ve a t and 75534. 1
undersiia at if the Sadocs not currently 25Shaveatenant,t534 it4my NEW RESIDENTIAL MECH. SQ.Ff.
mponsibilfty,to notify the occupant of the requirements which must be cart
prior to Issuance of a Cenificale of Occupancy. Nq
_ Imo,/, s
Owner or aulhoriud agent Date e� ISSURD BY:V V o �
'TOTAL: l e
OFFICE COPY