22055 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -.USE BALL POINT PEN ONLY
Building Proectddentl(Icathm - PlORMITNO.
Building Address:
la lbs ass= s, 22055
w n acre: one:'
CI TY OF CUPERTINO-BUILDING DIVISION ( 1^ I
•`:•" �dorpNa : S I�la.N.: APPLICATION / PERMIT �l 2Z-sl
I7 RLnDING-M BCIMCALIPLUMBING-MECHANICAL CATEGORY CONTROL N
.I e'Architeft/Engineer. Lie.No:
"' - QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: oil � SO PERMITISSUANCE ® ❑ ❑
LICENSED CONTRACTOR'S DECLAR TION
I
hereby affirm that IanoLceneed under provlsionsof Chapter9(commeme. APPLIANCES-RESIDENTIAL JOB DESCRIPTION
liense ISection force and affect.
and my
license le In full force and vireo. PANELS V-+
Licenso Class GlcN
Date Comrac or —UP TO 2DO ANTS
ARCHITECTS DECLARATION 201-1000 AMPS
q�q�va O I understand my plaru shall lie used as public records. OVER 1000 AMPSSQ.FT.FLOOR AREA $/SQ.FT.
Fi od Licensed Professional SIGNSELECTRICAL
(~n,aj� OWNER-BUILDER DECLARATION SPFGIALCERCUIT/M]SC
21" thereby affirm that l am exempt farm the Contractors Limme,Law for the
QQ owing reason.(Section 7031.5,Business and Professions Code:Any city or
p I-'cy follcounty which requires a permit to cowimprove,
troct,alter, demolish,or repair TEMP.METER OR POLE INST.
'� a anystm=mpriortoltsismance,alwmquirestheappHmntforsuchperMtto
file a signed statement that he V Licensed pursuant to IM provisions of the POWER DEVICES
O ty Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi.
EI alon3oflhe Bueineuand Praf.mW Code)orthathebemmptlhemfmmand VALUATION
SWIMMING]VOL ELECTRIC
'� •1 the basic for the alleged exemption. Any violation of Scolon 7e31S by any O Na
0
applicant for a permit subjects the applicant to a civil penalty of no more than OUTLETSSWDCHESFIXTURPS
five hundred dollars(5500).
�n ❑I,as owner of the property,or my employees with ween as there NEW RESIDENTIAL ELECTR sole �'FT' STORIES TYPE CONSTRUCTION
compensation,70KBuldothework and ions Code: Vnet
ntractror offered for
D sale(Sec.70K to Businessand Professions Code:The or imp core LIceme law
$ don notply torn imserofprough his
nem orlmprovnthereoryand
ch OCC,GROUP RES.UNH5
who
uressuch work himselfedoroughed ownemployees,Prot•Wedthat such
improvementsarenot intended earof dtoreio If,however, deer illhaveding or TOTAL:
Improvemsntbaoldwithlnareyaro(completlorytheowner-bullderwlllhave
e also of proving that he did not build or improve for purpose ofsale,). QTY; PLUMBING PERMIT FEE FLOOD ZONE APN
as owner of the property,am exclusWely contracting with licensed
tractors to consumer the project(Sm 70K Business and Professlons Code: PERMIT ISSUANCE
The Contractor's License Taw does no apply to an owner of property who ALTER-DRAIN&VEN7-WATER(FA)
builds or improve ct
thereon,and who contracts for such peo)es with a
co oarW licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
„Asa. L j I am exempt under Sec. B&P C for this reawnOUT-q1nF If
K4 :1 Owner • Date DRAINS FLOOR ROOF,AREA,CONT). SANITARY RECEIPT N
1 WORKMAN COMPENSATION DECLARATION
[:]I hereby affirm that I have a certificate of consent to ulfdnwre,ora FOCIlIRES PER TRAP SCHOOL TAX Y NRECEIPTcom icam of Wmken'Comperagkm Insurarmora certified copythemof(Sec.
3800,Lab C.) GAS EA.SYSTEM.1 WC.40UTLETS PARK FEE Y— N_
PolicyN RECEGAS EA.SYSTEM-OVER 4(EA) DING DI N
C. ray BUILDING DIVISION FE ES
❑Certified copy is hereby tthcity
e city
❑Certified copy V filed withh lM impaction dlWdon. GREASEANDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWEWSANITARY-STORM EA 200F1• Date Recei t#
(TMs section need rad 4 comploed Him Permit b(or ore hundred dellen
($100)otifyth WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
]certify that N the person In any m work fe,as to h ca permit slowed, —
I shall not employ any person In any manner act u to became subject to the WATER SYSTEM/3RFATING
Workere'Compensatlon laws of California.Date PAID
OZ NO I
Z O NOTICECE
TO APPLICANT.IL after muldng this Certl(kate of Exemption,you NEW RESIDENTIAL PLMB. SQ.FI', Date ReCei t# ,
should became subject to the Wmloare'Compensation provisioru of the Labor TOTAL:
N Code,you at forthwith comply with suchm
pWaimu or this permit hall be
LU ] dramad revoked. BUILDING FEE \
d C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affireathat there is a construction lending agency for the perfornF ELECTRIC FEE
,1
M Z anceoftheworkforwBfch this permit is Issued(Sec.3097,CIv:C.) TOTAL:
u2 Landers Name PLUMBING FEE
LL H Landers Addreas QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certify that l have read this application and elate that the above Wfomation
IL Iscormat.I agreeto comply with aft city and conamyordinanon and state laws PERMITISSUANCE FEES PAID:
>. - relatingtobuildinecommucdon,aced herebyauthorlzerepreaentalivesofthis
N
I" U) dtyloenterupon the abov&mentioned property for inspection purposes, ALTERORADDTOMECH. Date Recei t#
— Me)agree to saw,IndemNfy an d Loop harmless the City of Cupertino
against 16thfiRies,judgmenescoox.ed expenarewhich may In anywayaooue AIR HANDLING]INR(T010,000 CFM) SUBTOTAL:
ga a id Citymcarsequenm �(the granlln4ofthispenn .
a ^„ . _71 9 AIR HANDL NC UNIT(OVER IO,OODCFM) CONSTRUCTION TAX
SigreofAppHon[/Cntm&mr f Dal< -T EXHAUSTHOODOV/DLICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WilltheappHrant orfuture building occupant store or handle hazardous HEATING UNIT CIO 100,000 BTL])
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reeef t#
Health and Safety Cade Section 25532(W7 HEATING UNIT(OVER 10,000 BTI!) TOTAL: \
❑Yen No
Will the appUcard tore building occupant useequipmenl or device VENTILATION FAN(SINGLE RESID) DATE
which eMl hazardous air contaminants as defined by the Bay Area Air PjW
Quality Management DbMo7 BOILER-COMP DI-B'DR 10,000 BTU]
Fl Yn 9No (If'IT ov rr. 19��
have mad icaltha cue maerfals de,Sereont 2555,2553 and 25534.
of BOILER-COMP(OVER 100,000 BTU)
the
understandt Health&Safety Code,am correctly
andt,that I
mPOmaUity to lithebuildingthe occupant
note rmnllyharog which that llbmy NEW RESIDENTIAL MECIi. $Q.FI. SIA.K
rnporuiisemacenf aCtheoate Of oft he requlmmentswhich crest be mM R`I at
Prior to Lssuance o/a Certificate ofOnvpanry. �
(Tuner or aulhorba d agent DaleTOTAL: ISSUED
OFFICE COPY