22200 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ea Identification PERMIT NO.
Building Address: - - 22200
2214•, OR.CH11k6 C04IR-r
wren ante: one: p
eov C SGfa EGE2L _/A/ 7n 9E3 CITY OF CUPERTIN6BUILDING DIVISION ( -?9
Cmdractors Name: _ LIc.No. APPLICATION /PERMIT 7 'X 1�
BUILDING-M. MCALPLUMBING-MLCHANICAL CATEGORY CON m
Architect/Fagln r.. Lic.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
nddrcss PERA9TISSUANCE .2 1:1 ❑
LICENSED CONTRACTOR'S DECLARATION gI hereby affirm that l am licensed under provisions of Chapter 9(cormnerm APPUANCESRESIDENIAL IOB DFSCRB'1'ION
Ingwllh Section 7000)of Dlvtaon3oflhe Businessand ProfessionsCode,and my
license is in full force and effect. PANELS
License Class Lie.N SOD 1t�UJ
Dale CbntrachorUP TO 200 A
ARCHITECTS DECLARATION 2014000 AMPS
{qq{��r47 I understand my plans shall be used as public records. OVERIOOOAMPS SQ.Fr.FLOOR AREA $/SQ.ET.
E Licensed Professional r SIGNSELEC7RICAI.
OWNER-BNLOERDECLARATION SI'ECIALCBiCNT/MLSC
I„ Ihereby affirm that exempt from the Contractor's License Law for the
7 3 lollowin (Seel7LD1S,Business and Pro(essiona Code:An city -
gfeaSOn: on y ty or TEMP.METIR OR POLE INET.
countywhich requires a permit to construct,alter,improve,demolbh,or repair
Ky .'ti anysuuctvre prior to Its issaance,ahte requlresthe applicant(orsuch permit to POWER DEVICES
6 K file a signed tatement that W is licensed pursuant to the provisions of the ;
3 t., Contractor.License Law(Chapter9(commencing with Section 70110).(Diw- SWID{MINC IDOL ELECTRIC VALUATION
OGG cion 3 ofthe Buslnessand ProfessnioCode)orthat he is exempttherefromand
the basis for the alleged exemption. Any Wolatlon of Se ela7011-5 by any
¢OOU7LEISSW[TCF{F_SFlXNRES r tea/
applicant fora Permit subjects the applicant macivil penalty of not marc than
.. o five hundred dollars($500). NEW RESIDENTIAL ELECTR SQF. STORIES 7YPECONSIRUCTION
Q X11,as owner of the property,or my employees with wages as thele sale
�7Q cpemat[on,wllldothe work and the structure is not intended or offered for - -
,�i ❑ sale(Sec.7044,Business and Professions Code:The Contractors Llcene Law
p5$ does nolapply to an owner of propertywho builds orimpmvesthermq and OCC.GROUP RFS.UNITS
w whodoessuchworkhimvelforthwghhisownemployee%pmvideelthatsuch
improvemenbare notlnteaded oroffered(orsale.If,howevegthebuildlagor TOTAL: t
improvement mold within oneyearofeompirtion,the owner mi9derwill have
t�r +rdenof provingthat he did not Wild crimprove forp.rposeofaale.). QTY. PLUMBING PERMIT FEE
FLOOD ZONE MIN
.LJ L as owner of the mperty,am exclusively contracting with licensed
p
PERMIT ISSUANCE
contractons to construct the project(Sec.70K Business and Professions Code:
The Contmdor's License paw does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)
Wilds or Improve thereon, and who contracts for such projects with a FEE SUMMARY
n�tpfetor(s)licensed pursuant to the Contractor's License Law. BAIX CE
0I am exempt under Sec. B k P C for this reason _
FEES
u
Owner - Date W- DRAT R ODE'1 SANITARY Y N
D RECE Vr N
ORKMAN COMPENSATJONDECLAKAr�N SCHOOL 7A% Y N
F11m 1 hereby affirthat I have a certificate of consent to vel(-Inwre,ora I REGFLxf N
certificate of Workers Compenastlealmomace or a certi(lod mpythemof(Sec. GAS FA -i INCA .Ef PARK FEE Y N
Polk lab C.I RECEIPT N
Polity p GAS EA:SYSTEM Z
Com any BUILDING DIVISION FRES
[Certified copy Is hereby fumbhed. - GRFASEANDUSIRL WASTE INTERCEPTOR / PLANCHECKFEE
❑Cedified copy is filed with the city wpection divblon.
CERTIFICATE�OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200F7. Date RCCCI t# —IL
(This section need not be complesl If the permit b forom hundred dollar
(S)W)or pear.) WATFRIIEATIR W/VENT/dIiCTR ENERGYFEE Y_ 'N
Icedify that performance per(oance of the work for which baed
ch this permit is e ,
1 shall not employ any person In any tanner w as to become subject t.the WATER SYSTEM/TREATING
Wakens Compensation Laws of CahfcrNa. Date PAID
0 ApplicantDate a Rceei t#
ZZ NOTICETOAPPLICANT:E,aftar makingthls CeAffiateof Exemptin,you NFWRESIDENTIALPLMB. SQ.F`L
H0 should becomesubjecttothe Worker.'Compensation provbiomofthe Labor - TOTAL:
ir V) code,you at forthwith complywllhsueh provblonamthis pemNtshailW BUILDING FEE _
deemed revoked.
W ' CONSTRUCTION LENDING AGENCY SEISMIC PEE CL �L
MO I hereby r.fthe .,kfffiren thatherebacomtistano lending(Scc.397,Ciefor the perform- ELECTRIC FEE
0 Z ancedlhe work for which this permit hLvaed(Sec.3097,Civ.C.) TOTAL:
(� O Lender.Name PLUMBING FEE
LL F Lender's Aedreas QTY. MECHANICAL PERMIT FEE MECHANICAL ITE
U IomiJythm[hovemadthbappBeatbnandantethattheabovelnformation
0 W bcorrect.I a gree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} a relating to building comtrvctlon,and hemby authorize representativesofthis
I'— N etyto enterupon the above-mentioned property for inspection purposes. ALTERORADDTOMFGH.
? (We)agree to save,Indemnify and keep harmless the City of Cupedlno Date Receipt#
V agalrst liabNties,Jedgments,mets and expenses which may In anyway accrue AIR HANDLING UNIT(TO 10,000 CIM) SUBTOTAL:
against sa yin co uegcaoft granting of this permit
SAIR HANDLING IA9T(OVER ID,000CFM) CONSTRUCTION TAX
Signature of pBcant/Contractor - to EXHAUST HOOD IW/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfuture building occupant store or handle hardom HEATING UNIT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9AZ and the — ^
Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: LL-
❑Yes No
Will the applicant or future building occupant use equipment ordevices VFNILATION FAN(SINGLE RESID) - ISSUANCE DATE
which reit hammicus air conlamianbas defined by the Bay Area Air I{OILER CAMP(3EIP OR l00,IXD BTU)
...� Quality Management District?No - 6� .
I Yes Io No
have mad the haea-Flom materials requlremcnh under Chapter 6.95 of BOiL[R-COMP(OVER 100,000 BTU)
thecalifornlaliealthh Safety Code,Sectiom25505,25533and25534.I s i�F;�•
understand that lithe building does not wmantly have a tenant,that it is my NEW RESIDENTIAL MECH SQ.FT. -�
respomibllitytondlfytheoresp.ntoftherequinementswhlchmustbeme MP4
prior to issuance of a Certificate of Oaupanry.
Owner or aulhodud agent Dace TOTAL: ISSUED BY
OFFICE COPY R
c� J .