22010 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: arr 22010
Mi�}
nc a se: APPLICA nON sUBMi I IAL
y ,XM+ — ON.
CITY OF CUPERTINO-BUILDING DIVISION
.� Cono-actor'a a r APPLICATION /PERMIT "(
BUILDING-ELECTRICALMLYMBING-MECIIAMCAL CATEGORY CO OLX
Architect/ neer. .
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE DKI '
❑ ❑ ❑
JI
LICENSED CONTRACTOR'S DECLARATION — _
I hereby affirm )o MviMam m3ofthe usi, andP fenioer9( APPLIANG6RE9DENTIAL JOB DESCRIPTION
InenseIsi 4full 0)of Dleffect oftheBminessand Pro(aslonaCode, d 1
Ilcenseisi Ffudfect. PANELS
License LIc.M
Dale Contractor —so, UPT0200AHM
ARCH ITECPS I 201-1000A.MPS
a4 I understand my plans shall be used as publ ba. OVERIBOBAMPS _ SQ.FT.FLOOR AREA $/SQ.FT.
OC
(/ Licensed Professional SIGNS ELECTRICAL
<<of OWNER-BUILDER DECLARATION
ofSPECIAL CIRCUIT/MISE
I hereby i.., owingraffbmthatlamexempt 31-5,B(rotheossa Contractor's License Law fort he
9F— county whichon.quiremmn7¢U$Busineaand Professions Code:Any dtyor TEMP MEIFR OR POLE INS!.
3,
countywhichrequltesa psuancemmtmctlersthaprovgdemoibh,ormitI
anya signed paler leits hatMgaborcdpursuant to the revisionsorsuch of the ppyyFg DEVICES
g� �� 01e a signed statement that he V Ilernaed pursuant to the provisions o! the
pOw Conmidoes Liceme Law(Chapter 9(commencing with Section 7000)of Divi- VALUATION
W3022^ sion3ofthe Business and Profeasloru Code)orthat he b exempttherefromand SWIMMING POOL ELECTRIC p�
the basis for the alleged exemption. Any violation of Sectio703111 by any / Q p
4a. OUTLEISSWITCIiESFlXTURF5 0
applicant fora permit aubjeRsthe applicantt.acivil penalty o(na morethan
five hundred dollars(3500). NEW RESIDENTIAL ELECIR FT.
L as owner of the property,or he employes with wage as thele sok
SQ. STORIES TYPE CONSTRUCTION
pSec 7044,will Business
and rk,Pr and thestacture Is he et Contrendedactors
or iminse d for
Law
D vie(Sec 7034,to alnow and f grope oro Code:The Contractors thereon Law
$ docs nor apply loan owner orthrou h who Wildnem or improves yees,povided thereon,and
�^
who does such work himxlf orthr.ugh his ownemployees,provided that vch OCCGROUP RFS.UNITS
improvements am not Intended muttered forsale.If,however,thebulldingor TOTAL:
i provers nt issold withinoneyearofcompletion,theowner Wflderwill have
tke.hurden of proving that he did not bund or improve for purpose ofsale.). QTY. PLUMBING PERMIT FEE
Fl.00D ZOONE APN
I_I L as owner of the property,am exclusively contracting with licensed
PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER MA)
Wilds or improves therms,and who contracts for such projects with a FEE SUMMARY
contractoRa)licensed pursuant to the Contractor's If...Law. BACK FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B&P C for this reason
OUTSIDE FELS
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y_ N_
• Owner Date RECEPTN
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y_ N_
F-11 hereby affirm that 1 have oertlicate of consent to self-insure,a a RECEIPT N
3800 hal, eri ofWorkCompensatioo n lruurance oracerti�(kd/ropythpythereo((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Gollry N O O - ftGCLB'I N
Com crass GAS F.A.SYSTEM-0VER4(EA) BUILDING DIVISION FEES
Certifle apy�hr.byfumbhe II0. PLANCHECK FEE
Certified copy is flied with the city Inspection division. GREASE/LNDUSCRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE y-L�yER-yYMT.ARY-yTORM EA 200FT Date Recd t#
(This section need net be completed if the permit k for one hundred dollars
(s100)orless.) WATER7[FATER W/VENT/F1.EGTft ENERGYFEE Y_ N_
I ernify that in the performance of the work for which this permit Is issued,
I shall net employ any person in any manner so as to become wbje t to the WATER SYSTIM/.R EATING
Workers'Compensation laws of California.Date PAID
z Z NOUCETO APPLICANT:If,after making this Certificate of Exemption,you cant NEW RESIDENTW.PIMB. SQFT. Date Reml t#
FO should become subject to the Workeri Compenaati.n provisions.fthe Labor TOTAL:
ccN Code,you most forthwith comply with such provisions orthnr permit shall bc BUILDING FEE e D
W 9 dremed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
d Ihereby affirm that there is a commiction lending agency for the perform TOTAL: ELECTRIC FEE
Z ance ofthe work for which this permit is LssuN(See.3097,Civ.C.)
02 I.ender.N.me PLUMBING FEE
F Lender;Addreas QTY. MECHANICAL PERMIT FEE
U. F-
Irenifythat l have read this application and satethAthe.Woe InformationMECHANICAL FEE
O W Iscorred.Degree to comply with all city and county ordi cnanda.telaws PERMITISSUANCE FEES PAID:
>. C relating to Wilding construction,and hereby authonz p nmivea.fthb
W it to amara the above-mentioned property for ro Ion ALTER OR ADD TD MECH.
Z city p°" P pe1)' p"rpDe Date Receipt#
— (WeI gree to save,Indemnify an d keep Aar a t City of Cupertino AIR}dANDENC UMT(!010,000 CFM)
agalmt blWles,pdgmen de pensee Ich yin anywayacaue SUBTOTAL:
a alr�st aid City In con of the crating ft pertnl
(�j AIRHANDWNGUNI'f(OVFR10,000CFM1 CONSTRUCTION TAX
J CONSTRUCTION TAX PAID:
Signa p t orates Date IXHAUST HOOD(W/DUCT)
H ZARDOUSMATOU DISCLOSURE
Willtheap t or future building rat store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Mu ' pal Cade,Chapter 9.17,and the
I IeaRh and Safety Cod,Section 75537(a)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
Will the applicant., uture building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISJ DATE
which emit harardou.air contaminants as defined by the Bay Area At, as
• Quality Management District? BOILER-COMP QHPOR 100,000 BTU)
4Yea nn No TT[11
havemia theth&Safet materialsodeSe rcons 25SntsunderChapter. 1 of BOILER-COMP(OVER 100,000 BTU) (IPI
theentamia Health&Safety Code, currently
hvi5a tenant,andthat I
rodeo ixndthat If the notify
the occupant net a requirments which
that it mets my NEIN RESIDENTIAL AfECH. �.IT.
rapomibsato ofa theicapantoftherequlrementawhich mustW met saaad��p��
prior to issuance car's Certificate of Occupancy. lq wSfs'-11 n�
Owner or authorized agent Date TOTAL: ISSUED B _ �
OFFICE COPY