22764 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pruect Identification PERMIT NO.
Building Address: n/7 (�
X56 20 M'ar'l rr)a.r7 Pte. G G I6
, n�rns �a `� �-y� q A A
�hL-f—T' / N ie / �J-01 CITYOFCUPERTINO-BUILDING DIVISION �������
tr '9 Name. APPLICATION I PERMIT
BUILDING-ELECTRICAL(PLUMBING-MECHANICAL CATEGORY CONTROL N
Archite Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: -. PERMITISSUANCE /e IQ_ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION L�
Iherebcfi.r7 0) l tvtkensedunder pressandsof Chapter 9(commenc MPLIANC75RESTDENTIAL JOB DPSCRE"HON
Ingwith Section 7000)ol DiW91on3 the Bu nessand Pro(esslonsCAde,and my
license is ln�(ea. PATOIS fFia`�(at► f!
Lirensa Ch ICM
Datil 711"]1_ ContrUP TO ZMAMPS
FE 201-IMOAMPS -
1"�1a�7 ARCHITE 5 E A ON OVER IOOO AMPS �.Ff.I•LOOR AREA N'k`s/SQ.FT.
pod understand my plan ahaR be uxdapub creat ds n ® I ,
ua;d Licensed Professional SIGNSELECTRICAL lFi\`IJI /////--\1
�<¢w OWNER-BUILDER DECLARATION �.. n �J
7 Iherebyaffirmthat I am exempt feem the Contractor's License law for the SPECMLCIRCUIT/MISC IVB U T E R
70 following reason.(Section 71131.5,Bushes and Professions Code:Any city or TEMP.MEM OR POLE INST.
F71" county which requires a permit toconstrua,after,improve,demolish,oreepalr �j
anysimc mprlortoltsiswancealsorequtmtheappHuntfo wchpermittoPOWER DEVICES A.TE
a ilk a signed statement that he Is licensed pursuant to the provisions of the
Convaaors License Law(Chapter 9(commencing with Seaton 7)00).f Dlvl- SWIMMING POOL ELECTRIC A VALUATION
O<< slon3 ofthe Busums and Prdessbns Cade)orthat he is exert therefromand _
tP ^I the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETSSWITCHESFI
Mapplicant forapermitsubjectsthe applicant toacivil penalty of net morethan
five hundred dollars(SM. NEIN RESIDENKIALKTR
coF-1I,as owner of the property,or my employees with wages as their sole SQ.' STOW ES TYPE CONSTRICTION
mpensation,will do the work and the structure Is not Intended or offered for
psale(Sec.701k Business and Professions Code:The Contractofs License Law
$$ does not apply to an owner of property who W .
builds orlmpv.Ih=,and VOCC GROUP RFS.UNITS
whodoe9 suchworkhimeelf orthtough hlsownempinyees,provided thatmrch
improvements are not Wended oroffered forsale.If,however,thebullding or TOT
improvement issold within one yea rofcomplatioq the owner-budderwlll have
tl rden of proving that he did not build or improve for purpose of sale.). QTY. PING PERMIT FEE
LJ L as owner of the property,am exclusively contracting with Ilmose,1 FLOOD ZONE APN
contaaon to coretrua the project(Sec.7016,Business and Professions Code:
PERMIT ANCE
The Contactors License Law does nil apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or improvesas
thereon, and who contracts for such ptyjewith a FEE SUMMARY
Cp➢.t{aaor(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ 1 am exempt under Sec. B &P C for this reason
OUTSIDE ITES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPTN
. WORKMAN COMPENSATION DECLARATION re or FIXTURFS PER TRAP SCHOOL TAX Y N_
F11 hereby affirm that I have a cerHBvte of conxnt to self-inw RECEIPT N
cordflcateof Workers'Com I (Insurance r mrtl ropythereof(Sec. GAS EA.SYSTEM-I INCA OUTLETS PARK FEE Y_ N_
3X00,lab Q:)y.!) lI JUS—�1
v 1)y Gl RECEIPT
Company
mp p GAS EA.SYSTEM-0VER 6(EA) BUILDING DIVISION FEES
Com any a•r5a Q--I furnished. rad J
�CeAlliied copy Is fi dwiththecitGREASE/INDUSIRL WASE IMFRCEI'TOR PLANCFIECK FEB
„I�Cfrtifled copy b filed with the city inspection division.
CERTI"CATEOFEXEMPFIONFROMWORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWFII-SANITARY-STORM EA.2IIOFI. N I#.
(This section need net be completed if the permit ls for one hundred dollars Date R
(gl1))or less) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I coldly that in the performance of thework forwhich this permit Is Issued,
I shall not employ any person in any manner so a to become subject to the WATER SYSTEM/TREATING
Workers Compensation laws of California.Date0 Applicant
PAID
Z Z NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FT. Data Revel t#
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
2 in
Code,you must forthwith comply with such provisions or this permit shall be BUILDING •E
W ] deemed revoked.
CL G
CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihereby affirm that them Iso construction lending agency for the perform, TOTAL: ELECTRIC FEE
7 Z once.ftheworkforwhichthbperMtistswed(Sec.3097,CIV.C.)
U O Ierier•s Name PLUMBING FEE
LL F- I.ends,'BAddres9 QTY. MECHANICAL PERMIT FEE MECHANICAL FEE l
W lmdifythatihavemadthbappliutionandstatethattheab veinformation
O
Is cerrect.I cgree,to comply with all city and county ordinances and state laws PERMIT ISSUANCE /6 OU FEESPAID:
r N relatln building cons doter,and herebyauthodze repreaentativesofthIs
cit t ce run the abovrntloned ro for iv ion sa. ALTFRORADDTOMECH.
~ Z y e) �NwvaZ�de=Fify and keep M1armicss th City Cupedino Date Receipt#ag natha intsstsandexpenses wpn was rue AIR HANDLING UMI CTO l0,000CFM) SUBTOTAL:
ag Wtu oft anting of i
AIRHANDUNGUNT(OVERIQ"CFM) CONSTRUCTION TAX
Sigw fApplicant/Contractor Date IXHAUS'r HOOD M/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the a ppliunt or Whom building occupant store or hand is havrdous HEATING UNIT(TO 11),1)0 BTU) Date RCeef t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,01)BTU) TOTAL:
r]
QYa No VENTILATION FAN RESID)
Will the applicant air
emBding occupantuse equipment or devices ISSUANCE DATE
which emitnaement aircontaminantsa defined by the Bay Area Nr �-
Quality Management DisWa7 BOILER-COMP pM'DR 100,IX0 BTU) -
Ycs No
have read the bans ou9 materials requirements under Chapter 6.95 of BOILER COMP(OVER 100,000 BTL) LfABTk
the California Health&Safety Code,Sections 25505,25533 and 25534. I aELCT'R��N RpWR
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECIL SQ.FT.
responsibility to notify the occupant of the requircenents which most be met
prior to issuance of a Certificate of Occupancy. ar.�1�"y� � ���
Owner or authorised agent Data 15LIED By: ,V/sf/Vsss�m+
TOTAL:
OFFICE COPY