22079 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ed IdammeMim, PER.WTNO.
Bulldmg Addmes: '
75-16 Ora t o�Sa rl1v� 22079
ere .: 1 m OT w - A A JE
SC �,L
D'ai 9h" '1/ CITY OF CUPERTINO-BUILDING DIVISION . t��--�0
Contractors Name: Lie.No: APPLICATION / PERMIT 1•
BUILDINGELECTMCALMUMBING-MECHAMCAL CATEGORY CONTROL N
Amhlled/Engineer. Lic.No: -
_ QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addrc99: _ l PFRMITISSUANCE C� Pn ❑� 11LICENSED CONTRACTOR'S DECLARATION -
lhereby etfirentleat l am lcensed under provialona of Chapter9(commene- APPLIANCES-RESIDENTIAL JOB DESCKII-TION
Ing ase isifon700earindvfect. .(the Busirmsand ProlcssionaCode,and my
iIt ngwit le ecfun force and effect. PANELS
Licenee Clas LieN ,
Date Contractor
ARCHITECTS DECLARATION - 201-IOW AMPS
�'Z I understand my plamshallbe used as public records. - OVER IODO AMPS SQ.FF.FLOOR AREA S/SQ.FT.
oO
d u Licensed Professional SIGNSELECTRICAL
6 OWNER-BUILDER DECLARATION I SPECIALCIRCUIT/M19C ' -
1.., . 'I hereby affirm that am exempt from the Contractor's Limnse Law for the
7 O_ !.Vowing means.25ectlon 7031.5,Business and Profaslm a Code:Asy city or TEMJ - /Y D
Oz;' countywhlchrequlmsapertNttowmtmct,alter,Impmv,demolLh,°rrepalr P'MEFO20R POLE[NST. ,I I 1' 6110 E
qq`��O1nQ nyetmcturepr rtaisL ancgatsarequlreatheappBanlforsuchpermitto
K U file a signed statement that he,is licensed pursuant to the proetsums of the POWER DEVICES
3 n, Contractor's License Law(Chapter 9(commencing with Section 700D)of Divi- SWMIMING POOL ELECTRIC O�
P11 T
O salon 3 ofthe Businessand ProfesloseCode)orthat he le;exempt therefromand
a the basis for the alleged exemption. Any violation of Sectlon 70315 by any - OUTLETSSWITCHES-FIXTURES
appilant rot permit subjecatheappncamt°a dull penalty a not more than
q llve�reci dolleers(SS00). NEW RESIDENTIAL ELECTR SQXT.
ppp as owner of the property,or my employees with wages as their sale STORIES TYPECONSTRUCTION
CX compensation,wal clothe work and thestroa,ctub not Intended or offered for
O
sale(Sec.7014,Buslies,and Profesios Code:The Contractors Llcerae Law S$ does nolapply to an owner of property who builds or improves thereon,and RFS.UNITS
_
Improvements are not Intended croffered foe sale.If,however,thebullding or TOTAL: ! \ -
Improvementtasuld within°neyearofcompletiogtMe ner-budderwitl have '
t N
en of proving that M did not Wild or improve for purpose of sale.). QTy. PLUMBING PERMIT FEE
MI,as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
contractors to c.rotruct the project(Sec.7044,Business and Professions Code: PERMITISSUANCE
TM Conlradors License Law does net apply to an owner of property who -
Wilds or Improves thereon, and whomntnm for Such pPjed9 with a ALTER-DRAW Na VENT-WATER(EA)
c, eto )licensedp uant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
El alas un r Sec. B k P (ort ream - OUTSIDE FEES
DRAINSFLDDRROOF,AREA,COND. SANITARY Y_ N_
Owner -
Data
RFiCEIPI'N
WORKMANCOMP' SATIONDECLAR 'NMTURES
PER TRAP - SCIi00L TAX Y_ N_
❑I hereby affirm that I have a certificate of consent to set!-insure,ora RECEIPT N
M00,lab C.) S
artfIrate°/Workers'ComperoatimInsurance or a certified copy thereof(Sec. GAEA.SYSTEM-1 INCA OUTLEq'S PARK FEE Y N
_ RECEIPT N
Policy p GAS EA.SY$TFhI-0VER 4(EA) BUILDING DIVISION FEES
Co any � -
ffCertifiedcopybherebyfumished. - GREASE/INDUSIAL WASTE INTERCEPTOR PLANCI-TUCK PEE
❑CertJied copy Is filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID '
COMPENSATION INSURANCE SEWER-SANRAAY-SR]RM EA.200Ff. Date Recei O
(Thl9secti.e need set be completed lithe permit b for one hundmd dollars
(g100)or les.) - WATERHEATTRW/VENT/ELECTR ENERGY FEE Y_ N_
1 cerdlfythat N the performance ofthe work for which this precut Is tamed,
I shall not employ any pereon in any manner m as to Femme subject to the WATER SYSTEM/TREATING -
WOrkere'Compensation Tawe of Cailfornb. Date PAID
OZ Applicant NEW RESIDENTIALPLMB. SQFT. . Date Recei tN
Z O NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
should becomO subject to the Workers'Compensatl.n provisions of the Labor TOTAL:
N Code,you must(orthwllh comply with each provisions or this permitshall be BU D G
W j deemN revoked. ,
CONSTRUCTION LENDING AGENCY SEISMIC FEE -�-
a° PLUMBING FEE I hereby affirthatthem h a construction lending agency for the perform TOTAL: ELECTRIC FEE 5U
7 ance ofthe workforwhlchlhb permit is lareed(Sec.3097,CIv.C.)m
Z
(� O Lander'.Name "
f Icnder's Addres9 QTY. MECHANICAL PERMIT FEE
O w IcedifythatIhavereadthbapplication and statethattheaboveinformation MECHANICAL FEE
11 Is correct.I agree to comply with all city and county ordinances FR
and pate laws PMITISSUANCE FEES PAID:
>. relating to building construction,and hereby authotlu representatives of this
(— N city to enter upon the abovcmentioned property for Wpedlon purposea. ALTERORADDTOMECH.
Z Date Reaciptit
agree to save,Indemnity an d keep harmless the Clty Of Cupertino
V aga Ilablllties pd ntot,costsandexpenseawhlchoaylnanywayac u AIR HANDLING I1NR(IO 10,000 CFM) SUBTOTAL:
said 't In reof the grantingof this c t.
PV' ag'r nnp R HIMOOO
ANDUNG IT(OVER IQCr.M) CONSTRUCTION TAX
�I ����/- MR
TAX PAID:
Sighatureof Applicant/Contractor Dato EXHAUSTHODD(W/DUCT)
HALL RDOUS MATERIALS DISCLOSURE
CY Will thea applicant or future building t store or hand le hazardous. HEATING UNIT(TO t W,WO BTU
PP B emo W^ Date Rccci tN
I lealt
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
I lealth and Safety Code Section 75532G)7 [iFA71NC UNIT(OVER i W,OW BTU) TAL:
❑Yea. �]N° -
s
Will theappllant orfuNre building aavpart use equipment br devices VFNDLATION FAN(SINGLE RFSID)- � /I A/YI$$�N 'DATE
which emit hazardous air contaminants as defined by the Bay Area Air rlI J r7 9
Quality Mamgement Dixtrid7 BOILER-COMP(3FIPOR IW,OW BTU)' ' .
Yes
4havereadthe ha,,aFI�� o
rgoNmaterialsrequirementsunderChapter6.95of BOILER-COMP(OVER IW,0W81L) `
the California Health k Scanty CWd ,Seal°s 25505,25533 and 25536. I
understand that if the building does not currently have a tenant,that it b my NEW RESIDENTIAL MUCH. SQ.f•T �1^n
responsibility to notify the occupant of the requiem ents which at be met '
prior to issuance of a Cetlitlate of Occupancy. ,�
Owner or autharluTOTAL:
d agent Date ISSUED OT�ILo5N��,,Jjcr-�
OFFICE COPY