22987 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect IdentificationPERMITNO.
BuildingAddress:
22987
A A A
5 V�� -10 -rn $b CITY OF CUPERTINOBUILDING DIVISION � ��� 5.` A
ce^tract,%=Nam": Lic.No: APPLICATION / PERMIT J16,
Sate—, kK1.t•r J- NI r7 _ BUILDINGELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROLx
Architect/Eoglneee Llc.No:
a TY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: q�Noj&�C -2)y-5 6#IdAJ '14 PERMITISSUANCE � ❑ 1*-- ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter9(commenc APPLIANCES.RFADENTIAL JOB^w�1nNw{P
ingwith Section 7")of Dlvislon3ofthe Bosunsand PmtesslonsCode,and my moo ��T
PPOL
license le In full force and eff et PANELS
LiceDate Claes LION
Dale Contractor 7011000 AMPS —"
UP TO 2N AMPS
ARCHITECT'S DECLARATION OVERIMAMPS �SQ AR S/SQFT
I understand my plaru shall be used as public records.
LITER
m b U Licensed Professional SIGNS ELECTRICAL ^
R,<N" OWNER-BUILDER DECLARATION SPECLILCE2CUIT/M15C P
z l.., 7 I hereby affirmthat l am exempt fromthe Contractor's License law for the n `n
O 0_ following reason.(Section 70315,Bmines and Pro(esions Code:Any city or TEMP,METER OR POLE INST.
F' county which requires a permit tocowtruct,alter,improve,dermolish,or repair y
r49'cn anystmMmprlorlo RSLsmanc aL requirestheappHmntfmsuchper tto POWER DEVICES
O�V file a signed statement that he h licensed pursuant to the provision of the
3°, Contractors License Law(Chapler9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
0� sion3ofthe Businesand Profs WmCWe)orthat heisexempitherefromand
�^ the basis for the alleged exemption. Any violation of Section 70315 by any OUTLETS-SWITCHES applicant for a permit subject the applicant to a civil penalty of net more than
e, five hundred dollars(SM. NEW RESIDENTIAL ELECTR PT.
I,as owner of the property, SQ STORIES TYPECONSTRUCTION
.-�n ❑ p perty,or my employees with wage as their sole
kZ< compensation,Business and randthestmcturehe Contactor La=Law
9 O see(Sec appy to Businessand
property
Code:The Contractors thereon Law
S doesnotsuch apply roan owrurofprough hisonempbuilds oym,prvidedr improves that such
OCG GROUP R}S,UNITS
FS^ whodmauch am net umededorough hlsowne.Iflim,proviebuildtsuch
improvementsarenm Intended earrifoo for sale.I(hower,W13derwilingve TO
improvement b sold within oruyearofcompietmq the owner-builder will have
t"nlen of proving that he did notbuudorimprovetorpurposeofsale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
u I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractor m construct the project(Sec.7044,Business and Professions Code:
The Contractor's Llcene,Lw don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)builds or Improves thereon, and who contracts for such ptojeRa with a FEE SUMMARY
et,Aactor(s)hemsed pursuant to the Contractor'sWcense Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for this reasonOUTSIDE FEES
DRAINS FLOOR,ROOF,ARECOND. SANITARY Y_ N_
Owner Date A, R1LE11'TN
Wall]=tAN I have a COMPENSATION DECLARATION SQi00L TAX Y_ N_
❑[hereby affirm that I have a certificate of consent to self-Insure,ora FTX'IVRFS PER TRAP RECEIPT N
certificate of Workem'Compereation Insurance or a certified copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
�3800,Lab C.) _
I'ollryp .s GAS FA.SYSTEM-OVER4(EA) DINGRIKETN
( _ BUILDING DIVISION FEES
rtifi cop "� GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified ropy E filed with the city Irupectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANRAAY-STORM EA.700FT. Date Remi t#
(Thlssectlon need not be completed lithe permit Ls(or one hundred dollars
(8100)mIms.) WAT[R I-IEATEi w/Vi1JT/ELLCTR ENERGY FEE Y_ N_
I certify that in the performance of thework(orwhlch this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATERSYSTEM/TREATING
Workers Compensation Laws c1 GII(rrnla. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQjrL Date Repel t#
Z O NOTICE TO APPLICANT.If,after making this Certlflrale of Exemption,you
should become subject t"the Workers Compensation provislom of the Labor TOTAL:
N Coda you must forthwith comply with such provisions orthis permit shall be BUILDING FEE
W > deemed revoked.
'
CONSTRUCTION LENDING SEISMIC FEE
a S
Ihereby.flim,thattheworkforw there Lseromtruction lendingisissud(See. ,cy Civ.C.) perform TOTAL. ELECTRIC FEE
7 Z once o(theworkfor which this Permit is issued(See.3097,Civ.CJ PLUMBING FEE
u O lenders Name
Lender'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1mrllfythatl have madthb applicatlonand statethattheabove Information
IL corect.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. elating to building construction,and hereby authorize representatives of this
F IL W city to enter a Pon the abovementlonel property for inspection purposes. ALTERORADDIOMECH. Date RCCCIPt#
(We)agree to save,indemnify an d kpe harmine the City of CupedIno MR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
V .,al. Ilitio,pd rata coatsandexpensn which cosy ln• y me
a aim sal Cigspn s tto(the granting of thio permit CONSTRUCTION TAX
��. glgl AIR HANDLING UNIT(OVER Io,000C[M)
Signature of App cant/C rat actor Da //— EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous HEATING UNIT(10 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Health and Safety Code Section 25532(a)2 BEATING UNIT(OVER 100,000 BM TOT
❑Yes No
Will the a ppliunt or m e building occupant use equipment or device VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit lamniom air contaro a rats as defined by the Bay Arca Air
® Quality Management District BOILER-COMP QHPOR 100,000 BM
Y. No
have read the b.9 us materials mquircments under Chapter 6.95 of BOILER-COMP(OVERIM,"BTU)
the Califarnia Health&Safety Code,Stolons 25505,25533 and 25534. 1 NOV 15 1991
understand that if the building don not currently have a tenant,that it is my NEVIRESIDENTIALMECH. SQ.FT
responsibility to notify the occupant of the requirements which must be matt
priortoi uanmofaCertifcateofCa panty. Cllr V V
/�F nUptHI IIVV
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE COPY /