22255 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Project Identification PILMTT NO.
/
Building Address: one.
22255
a A A
sura CITY OF CUPERTIN0.BUILDING DIVISION
C. gramme; Z .. APPLICATION / PERMIT "L
BUILDINGUBC-MCALML BINC MECHAMCAL CATEDDCONTROL X
Archlt Enginser. Lic N.
Qn ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Ad rens: Zr O 0 PERNITISSUANCE ❑ ❑ ❑
LICENSE CONTRACT R'S DECLARATION
I hereby affirm that l am Ecensed under immeblons of Chapter9(mmmenc- APPUANCESRESIDESIMI, JOB DESCRIPTION
(ngwith Sedion7000)of Dlvision3ofthe Buslnessand Pmfe wsCode,and my (� �(�,ti a
license binfu0 and dfea.Z !'ir 6 PANELS --1 t-'<--W
LicenseCh LIC M_ _'RO� `\
Date Contractor
ARCHITECT RATIO 201"1000 ANTI'S
p'L I understand eny plana shall be used as public rcooda. OVER 1000 ANTI'S SQ.FT.FLOOR AREA $/SQ.FT.
OCC
Licensed Professional SIGNS ELECTRICAL
6Q OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MLSC
sp., y mving rasson.Cenion7313,B from the d Professions
License law fort he
ZOZt-'a (albwing reason.(Sectlon 70315,Business and Profeniona Code:Any city or TEMP.METER OR POLE INST.
rountywhich requires a pertdt tommtmd,alter,improve,demoibh.orrepalr
q < anystmaure,prior to Its matance,alsorequires theappliant forsuch permit m
POWER DEVICES
EE V file a signed statement that he as licensed pursuant to the provisions or the
Oft
Contractor's License Law(Chapter 9(commencing with Section 700())of Divi- SWIMMING POOL ELECTRIC
30�^ sion3ofthe BuMnenand ProfessiomCode)orthathebexemptthemfromand VALUATION
y.'S the basis for the alleged exemption. Any violation of Seaton 70315 by any OUTLETS SWITCHES-FIXTURES
<O 5.
applicant for.permitsubjedstheapp0anttoadvilpemltyafna monethan
five hundred dollars($.500). NEWRFSIDENTIALELECTR SQFT. STORIES TYPECONSTRUCTION
❑I,as owner of the property,or my employees with wages as their sole
�7Q compensation,will do the work.and the structure Is not intended or offered for
❑
Is(Sec.7014,Business and Professions Code:The Contractors License Law
Pj5$ docs not apply to an owner of property who builds or impetus thereon,and OCC.GROUP RFS.UNIT'S
C. who dcessuch work himself or through his own employees,provided that such
improvements arc not Intended oroffered for sale.If,howeveq the building or TOTAL:
improvement taaold within omyearofcompldkgtheowner-bu0derw111 have
t den of proving that M did not build orimpmve for purpose ofsale.). QTY. PLUMBING PERMIT FEEFIAODyDNE APN
Lj L as owner of the property,am exclusively commuting with licensed PERM117133UANCE
mntraama to construct the project(Sec.7044,Business and Professions Code:
The Controaor's License Law does not apply to an owner of property who ALTER-DRAIN A VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such pta
ojes with a FEE SUMMARY
oaaor(e)licensed purmxnttoths Comrador's Lkenne Law.
bBACK FLOW PROTECT.DEVICE
I am exempt under Sec B A P C for this reason s
DRAINS FLOOR ROOF,AREA,CONT). SANITARY Y_ N_
Owner Date RFCF]PT N
Of
here WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCIiOOL TAX Y_ N_
by affirm that I have a certificate of consent to self-Insure,or a RECEIPT'I
mdifiateorWmken'Compensation Insurance oracedfed mpythermf(Sec. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3000,lab C.)
RECEIPT p
I'oliq p
CGAS EA.SYSTEM-OVER 4(EA) BUILDING DIVISION FEES
C. any _
gzified copy es hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECKFEE
GP Certified copy b filed with the city inspection division.
��11 CERTIFICATE OF IXEMPTION FROM WORKERS' GREASETAAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA MFT. Date ReceI of
(Thiasedion need not ice complded I(the permit V(Drone hundred dollars
($100)rrless.) WATERITEATERW/VENT/ELECTR ENERGY FEE Y_ N_
I certify that in the performance of the work forwhlch thin permit Is Issued,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATING
Workers'Compensmion Iowa of Cablfornla.Date PAID
O Z Applicant NEW RESIDFNTIAL PLMB. SQ}T. Date Recei tt!
ZO NOTICETO APPLICANT.U,after making this Cedtiate of Exemption,you
H W should become aub}xt to the Workers'Compensation provisions fthe Labor TOTAL:
Code,you=at forthwith comply with such provisions or this permit shall be BUILDING FE
deemed revoked.
LU CONSTRUCTION LENDING AGENCY SEISMIC FEE
a O Ihereby affirm that there is a constmetion lending agency for the perform- TOTAL: C ELECTRIC FEE
D Z ante or the work for which this permit is Issued(Ser.3097,Civ.C.) PLUMBING FEE
02 Lenders Name
U. F 1,enders Addrens QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W IaN(ythatl havereadthisapplicationand aatethattheabovelofomution
beermd.I agreeto complywith allcityand muntyodlnancesand date lawn PERMIT ISSUANCE FEES PAID:
r d miatuittobulldingmnstrudion,and herebyawhorize representativesafthis
F N citytoenterupon the abovnmentloned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receiptq
V against liabilities,judgments, P Y^ Y Y AIR HANDLING UNIT U010,000 CFM) SUBTOTAL:
d ts,meta end ex coxa which may I an ova amrue
Z By In consequence of the grant goft permit. CONSTRUCTION TAX
� ) AIRHANDLINGUNR(OVFRI0,000CFMI
u�
Igo q pplHAntntraaor Dat IXHAIIS"T HOOD(W/DI1C'D CONSTRUCTION TAX PAID:
HURDDUS MATERIALS DISCLOS E
Will the defined or by
upbuilding occupant Code, hhandle h,adous ITEATING UNIT(TO 100,000 BTU) Date RCceip[N
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I icalth and Safety Code Section 75532(.)7 HEATING UMT(OVER 100,000 BTU) TOTAL: k
n Yes ri No
Will the applicant orfuture building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) h—I SULANCE DATE
which emit hmadous air coma Heartsas defined by the Bay Arca Air
• Quality Management District? BOILER-COMP OLIPOR 100,000 BTU) t ^'
4Yrs j^L�JNo M�If , , cJ
havercadthe hacaf�Ounmatcri.l mcf ircenentsuoderChapter6.9Sor BOILER-COMP(OVIR100,000 BTU) 2 ISN-1
the Ulifornia Health A Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building does not currently have.tenant that it is my NEW RESIDENTIAL MECH. SQ.FT. Pits,aaa/s.�
responsibility to notify the occupant of the requirements which must be met 11R eoiL 1IMI"Qu
prior to Issuance of a Certificate of Occupancy.
,�Owner or author)dagent Date ISSUED B
TOTAL:
OFFICE COPY