22523 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22523
f ' �
era ane A A
CITY OF CUPERTINO-BUILDING DIVISION N
cn ad sName: APPLICATION / PERMIT
EI
BUILDING MECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL p
ArchBe gin r. s Llc.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: _ PFRMITISSUANCE ❑ 1-� ❑
LICENSED CONTRACT 'S DECLARATION
I heh Secti ,70Matl iv Bcensedund sinessslonso(Cssiona cdeanmc- APPLIANCESRESIDENTIAL JOB DFSCRNTION
Ingwlt I Ifon7000)of d dieon3ofthe Buslnessand ProfesalonsCode,and my -
Iicense Is in fol and effect. PANELShCIJI
Liven .1 roe Lk.trgq
d c , /
Date Contractor (` �.
ARCHITECTS DECLARATI 201.1ER 10 AMP"'
gaCZ Iunderstand my platy shall be used upubR<recorda. OVERIWO AMPS FT MOOR AREA ED � S/SQ.FT.
2(d Licensed Professional 9GN5 ELECTRICAL _ {/�
OWNER-BUILDER DECLARATION �+ (] II B a�
1n Fn SPECIAL CIRCUIT/MCMC ve gVp H
(, Ihereby a(firmthat lam exempt from the Contractor's License law for the
ZO f. following reason.(Section 7031.5,Business and Professions Code:Any,city or q TEMP.METER OR POLE INST.
cou /
ntywhich rNulres a permit to wmtmd,alter,impmve, mo
delbh,orrepair 4.iel anystructum prior to Its beuance,also requlrestheapplicantfor such permit to POWER DEVICES TE f
If
file a signed statement that he is licensed pursuant to the provisions of the --------------
Commences
Commenc s License Law(Chapter 9(commencing with Section 7")of Divi- SWIMMING POOL ELECTRIC
alon3of the Busineasand ProleaskmaCode)or that he is exem therefrom.mi VALUATION
H 6 5 the basis for the alleged exemption. Any violation of Sc .c[ t 7MIS by any OUTLETSSWITCHESFIXTURFS j QQ aCnj
appBantfora permit subjects the applicant to a civil penalty ofnat morethan
five hundred dollars(S500). NEW RESIDENTIAL RLECTR SQXT. STORIES TYPE CONSTRUCTION
7¢ ❑I,as owner of the property,or my employees with wages as their sole
compensatlon,will do the work and the structure Whet intended or offered for
❑ sa1e(See.70"BusIfteas and Professhms Code:The Cmireciots License Law
does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UNITS
who does such work himself or through his own employees,provided that such
improvements are not Intended oroffered for sale.If,however,thebuilding or TOTAL:
improvement issold within oneyearofcompletion,the owner-bullderwlli have
the4urden of proving that he dm not build or Improve for purpose of sale.). QTY. PLUMBING PERMIT FEE ROOOZONE APN
LJ L as owner of the property,am exclusively contracting with Ilcensed PERMIT ISSUANCE
contractors to construct the project(Sec.7044,Business and Podesslore Code:
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
builds or Improves thereon, and who contracts for such pWiects with a FEE SUMMARY
,,➢➢.tpursuant...[[actods)licensed pursuano the Contractors License Law. FEE
FLOW PROTECT.DEVICE
LJ I am exempt under Sec. B &P C for thin reason
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT p
WORKMAN COMPENSATION DECLARATION1 FIXTURES.PER TRAM' SCHOOL TAX Y_ N_
F-11 hereby affirm that I have a certifiate of consent to self-Inmre,or a RECEIPT p
rertificateo(Workers Com nsat/loyn ire4J/yance ora certified copy thereof(See. GAS E.A.SYSTEM-1 INCA OUTLETS PARK FTE Y_ N_
3500,Mab C.) / �� 9% ! i
Policy p L. GAS P.A.SYSTEM-OVER 4(EA) DING Dr p
Cc��mPPany CE,.JO (� 6)• BUILDING DIVISION FEES
IXI Cen111ZLd�W e r 1 GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
I7�JS Certified copy W filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2WFT. Date Recei t#
(Thissedim,need not be completed if the permit W(none hundred dollars
(S10)(I)oriese.) WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that in the performance of the work forwhich this permit is Issued,
I shall not employ an/person In any manner so u to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
O Z Applicant NEW RES[DEN'TfAl P[.MB. SQFI'. Date Recei t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
CCN Code,you=at forthwith comply with such provisions orthis permit shall be BUILDING FEE
LU j deemed revoked.
CONSTRUCTION LENDING AGENCY SEISMIC FEE
' a a Ihereby affirmthat there Waconstruction lending agency for the perform- ELECTRIC FEE
TOTAL:
M Z once of the work forwplchlhW�RfermitWWsued(Sec.3097,Civ.CJ `
V O Lender§Name NQ h C PLUMBING FEE T leu
F Lender's Address QTY. MECHANICAL PERMIT FEE
O w1¢rtifythat I have read this appliationand state that the above information MECHANICAL FEE
1 correct.l agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>_ N relating to building construction,and hereby authorize representatives ofthis
cit to entero upon above-mentioned for bin ection purposes. ALTER OR ADD TO MECH.
h Z y P° indemnify keep F F rP° Date Receipt#
O �er;
labg111t1ea,judg e to save, ots,msand keep harmless the in anyway
Cupertinoaccrue AIR HANDLING UNIT CFO 10,000 CFM)
aga � expenaeaw y ywayaecroe SUBTOTAL:
a nst aid Gty Inc equen o e graining of this permit.
AIR HANDLING UNIT(OVER lO,WOCFM) CONSTRUCTION TAX
aCONSTRUCTION TAX PAID:
Igrsture of Applicant/ ntractor Date D(HASJS'C HOOD(W/DUCT)
HAZARDOUS MAT MALS DISCLOSURE
Will the applicant or future buildingMunicipal
ode, hapten 9.hazardous HEATING UMT(TO 100,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Cods Chapter 9.12,and the
health and Safely Code Section 15532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL x
E3Yea ,I+7..��I No .
Will the applicant or2ture building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air ��
Quality Management D❑istrict? BOILER-COMP QHP OR 100,000 BTU)
4 Yes N No
haveread ealtha matde,Se tionsZ 5,2553erChapter.1 of BOILER-COMP(OVQt l00,000BN) RUea
the California Health&SafetyCode,not currently h,25533and2553t It IT U
understand that notifybuilding doesthe
of to currently havewhicht,thatb isot NEW RESIDENTIAL MCCH. SQ.FT.
responsibility to notify<he ompant of the requirements which most be met aw��.
prior to issuance of a Certificate of Occupancy. 6*
of
Owner or authorized TOTAL:
agent Date ISSUED
OFFICE COPY