22136 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22136
kco2-z "('A)SCAOL CSIu ' C'u W
sr amy one: rAPPLICA A
Ives CITY OF PERTTN0.6UILDING DIVISION q /
C.
APPLICATION p� LIc.Na: APPLICATION /PERMIT — C
. c BUILDING-ELECIWCALFLUMBING-MECHAMCAL CA'ILCARY CONTROL
AEngine Lie No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: — PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyaffirm that l am Lcesad under provbionsof Chapler9(commen APPWANCESRESIDENTIAL JOB DESCRIPTION
Ingwith Section7000)of DlvWon3 ofthe BusinessandProfesionsCode,and my
license 1.in full force and effect. PANELSPe.�c
License Chs LIc.X UP TO 2DO AHfz
` _ � 1
Date Contador 2011000 AMPS V V d w
ARC hall Int s DECLARATION OVER IWe AMPS SQ.FT.FLOOR AREA $/SQ
�7 I understand my plans dull be used a public records '
O
Fj Licensed Professional SIGNS ELECTRICAL
Q W OWNER-BUILDER DECLARATION
7 j Ihereby affirm that l am exempt from the Contractor's License Law forthe SPECIALCRRCUIT/MISC
oo following reason.(lection 7071.5,Bushes and Professions Code:My city or
6Zs'a county which requires a permit to construct,alter,improve,demolish,or repair TEMP.METER OR POLE INST.
�e`S any structure prior to lb luuance,also requires the applicant for such permit to
file a signed statement that he is Bernard pursuant to the provtsios of the
OIe., Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi- SRI WIdARNC D
RI05 slon3ofthe Bunko.and Prof.1mu Code)mthat hrisexempttherefromand VALUADN 44
g 6 5 the busts for the alleged exemption. Any vlolatlon of Section 7MIS by any OUTLETS I pT pS ^"� )
,p,a applicant for a permit subjects the a ppllcant to a civil penalty of not more than -�T ( V
C o five hundred dollars 35M. N6w.RFSIDFSJliAJ1 E S ,I•T, W15 'TYPE CONSTRUCTION
7< �1,as owner of the property,or my employ,with wages as thdr sole
compensatlon,willdo the work,andthe.tacture ts not Intended or offered far
5 p sale(Sec.7044,Business and Professions Code:The Contractor.License Law
$ does not apply to an owner of property who builds or improves thereon,and OCC.GROUP RPS.UNITS
c, whodesssuchwork himselforthrough hhown employees provided that such
improvements arc not intended oroffered forsale.If,however,thebulWing or TOTAL:
Improvement issold withinoneyearofcomplMbmtheowner-W Oderwill have
tlfsrden of proving that he did not Wild or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE F DZONE APN
LJ I,as owner of the property,am exclusively contracting with licensed PERMITISSUANCE
contactom to construct the Ponca(Sec.7016,Bushes and Prefesios Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Imp.thereon,and who contracts for such pRajeas with a ALTFR-DRAIN&VENT-WATER(EA)
contractor(.)Learned pursuant to the Contactor.Lt...Law. FEE SUMMARY
LJI am exempt under Sec. B&P C for thin reason BACKFLOW PROTECT.DEVICE
OUTSIDE FITS
DRAINS FLOORROOF,AREA,COND. SANITARY Y N
Owner ftECEIIxT N
WORKMAN COMPENSATION DECLARATION FO(TIIRES PER TRAP SCIiOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to self-Inare,or RECEIVr X
certificate of Workers'Compecoation Insurance or a certified copy theaof(Sm. GAS EA.SYSTEM-1 INCA OUTLETS PANKFEE Y N
3800,Tub Q
RrCEIPT#
Policy N
C[PCGAS EA.SYSTEM-OVER 4(EA) BUILDING DI VISION ill ES
om any
crtiBed copy Is hereby furnished. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
MCcAffied copy Is filed with the city Inspection division.
F(�,U U
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE IRNr PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 200FT Date Recei t#
(Thisseettion needet b
ne completed if the permit ts s farohundred dollars
(SIW)orles.) wAreR tTFArtxw/vENT/ELECTR ENERGY FEE Y_ N_
I notify that In the performance of the work forwhich this permit 1.tssued,
I.hall net employ any n in any manner t become subject to the WATER SYSTEM/TREATING
Workers'Com a Tpnp[e6gy�ya fCalforgy�yJgato�eas PAID
O 'Applicant P/1.-Wzg2_(�LJ'/ Date Rectal t#
Z Z NOTICE TOA PLICAS R,after making titin Certificate of fEsemptlon,you NEW RESIDENTIAL PLMR. SQFT.
O should become subject to the Workeri Compesation provisions of the Labor TOTAL:
N Code,you mast forthwith comply with such provisime,orthis permit shall be BUILDING FEE .OD
W j deemed revoked. SEISMIC FEE 3.
CONSTRUCTION LENDING AGENCY
d I hereby affrmthat there is a construction lending agency for the perform, TOTAL: ELECTRIC FEE
7 Z ane,of the work for which this permit h 0.wedl Cec.3097,Civ.CJ PLUMBING FEE
(� Q Lender.Narre
U. F Lendee.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
W ER
1 certify that l have read this applicatlonand nmv atethat theabInformation
O 1,correct.4agree to comply with all city and county ordinances and state law. PERMIT ISSUANCE FEES PAID:
a
y relating rebuilding construction,and hereby authorlu representatives ofthts
Zcity to enter upon the above-mentioned property for inspection pection purposes. ALTOR ADD TO MECH. Date Receipt#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V against liabilities,pd eats,consand expenses which may In anywayaccom AIR HANDLING UNIT(TO to"CFM) SUBTOTAL: rs
against.ald li n saquc ce of theypnung of this permit. CONSTRUCTION TAX
(�11% AIR)iANDWNGUNIT(OVER IO,000CFM)
xStgnatu*.7 Applcant/Contractor Date % FAHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA7A R DOLS MATERIALS DISCLOSURE
Will the applicant orfutum building occupant store or hand le It v mous HEATING UNIT(TO t W CDO BM Date Rccel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Iiealth and Safety Cade Seaton 25532(.)7 HEATING UNIT(OVER 100,00)BTU) TOTAL:
❑ Ys M No
Will the applicant or fumm building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) [SEW DATE
which cont havardoua air contaminants as defined by the Bay Area Air �Rm°X�'
Quality Management District? BOILER-CAMP OTR'OR 100,000 BTU)
4Yo, i Nona
havomadtheh r`iiousmaterials requirements under Chapter 6.95of BO R- LR 7 �
the California I iealth&Safety Code,Sections 25505.25S33 and 25534.I 1
understand that if the building does not currently havnatena.I,that it is my NEW RESIDENTIAL MECTi. SQ.FT.
responsibility to notify the occupant of the requirements which=at be met
priori.issuanceof a Certificate of Occupancy.
Ownerorauthoriadagent Date ISSUED BY: w��J
TOTAL:
OFFICE COPY