22490 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Belittles Project Identification PERMIT NO,
Building Add...: 2 2 4 9 0
Ill's
w e . sane: one: APPLICATION sUuMu I AC=
Z • CITY OF CUPERTINO-BUILDING DIVISION
Nacon:. Lkc.No: APPLICATION if PERMIT
°ntra or.
BUILDINGE.ECTRICAUMUMBING-MECHANICAL CATEGORYCONTROL M
Architect/Engineer. - LM.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ �1. ❑
LICENSED CONTRACTOR'S DECLARATION
t hehSyd!trmB).f Dt l.e3.fheB.9rovblone°(Cervi... adeandn APPLIANCFSRESIDENITAL JOB DESCRIPTION
inense I Section 7000)01 d afelon3o(Ihe BuNneuand Pro/euloneCod<,and my F
lianas le I.ie(sal force and effect. PANELS
DateLicenClass Llc.a
Date Contndor —UP TO 200 AhTS
ARCHITECTS DECLARATION 201-IODO AMPS
q�q�vv a0 ZO I understand my plane shall be used u public records. OVER 10D0 AMPS SQ.FT.FLOOR AREA $/SQ.FF.
E o Licensed Professional SICNSELECIRICAL
�<<6 ° OWNER-BUILDER DECLARATION SPLCIALC@CUIT/MLSC
Z m t-, 1herebya(firmthat l aexempt from the Contactor.Llanse law for the
qqqqq followingmason.05etllon70315,Bu.lnessand Pro(enbns Code Anydtyor
F F N caunywhichrcqu4oa permit W mounted,alter,Improve,demolish,°reepair IL•MP.METRORPOLEINST.
�� a anyetmenom Edonc,its be.ance,abo requirestheapplant(orsuch permit to POWER DEVICES
c.V file a signed statement that he b licensed pursuant to the proNikon of the
OEt; Contactors License Law(Chapter 9(commencing with Section 700D)of CIA.
ElOn alon3ofthe Busineseand ProfesslonCode)orthat hebexempt iherefromand SWIMMING POOL ELECTRIC VALUATION
the Ixteb(or the alleged exemption. Any vkokalion of Sectio°7mIS by any
<� appBantforaper isubjedstheappleantloadvilpeultyofndmorcthan OUTLETSSWITCHE&FIXf11RES
AIva unetted dollars($SOD). NEW RESIDENTIAL ELECTR
�n I as owner of the properly,or my employees with wages as their sole 'rRI
SQ ' STORIES TYPE CONSTRUCTION
A1
nation,wlfdothe work,and thesouctum is net Intended or offered for
p sale(Se.7044,Box],and Pe fmioru Code:The Cmd.d.e.Lt..Law
does not apply to an owner of property who Wilda or Improves thereon,and
c- �^ whodousochworkhi.l(Orth.ghhi.ownemployres,providadthatesch OCC.GROUP RES.UNITS
Improvements arc not Intended oroffered for ale.If,however,the W ilding or TOTAL:
Improvement b sold within oneyearofcompletlor,the owner-bulkier will have
l
nip Ing that he did not Wild or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
�jo
as
owner of the property,am exclusively contracting with licensed PERMITISSUANCE �rx-�
con don to construct the project(Sec 7004,Business and Profession Code: W
The ntadoes License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or improves thereon, and who contracts for such p�o)eda with a
d�R(+da(e)licensed pursuant to the Common r�License Law. FEE SUMMARY
LJ I am exempt under Sen B &P C for this mason BACK FLOW PROTECT.DEVICE
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
RECEIPT Y
WORKMAN COMPENSATION DECLARATION rr^^ FD(TURES.PER TRAP SQdOOL TAX Y N
❑I hereby affirm that 1 have a certificate of consent to self-inwre,or V RECEIPT M
3800,laof Worken'Compeuatlonlnsuranre ore certlfkd ropythercof(Sec. GAS EA.SYSTEM.1 INCA OUTLETS
Policy
labb C.) PARK FEE Y_ N_
Poliry p RECEIDING DI M
Com any GAS EA.$YSTE.1.OVER6(EA) BUILDING DIVISION FEES
�Conifled copy b herebyth the city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECKFEE
❑CZffied copy is filed with the city Impaction division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRAP PAID
' COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200717. Date Recei t#
Ohi.secti.n need not becompleted If the permit b(or one hundred dollen
($1ID)oifyth WATER HEATER W/VENT/E.CCTR ENERGYFEE Y N
I certify thato the person nceoftheworkmanner an as to become
permit1.clamed,
I shall not employ any person In any manner so u to become aubjed to the WATER SYSTEM/TREATING
Workers!Compensation laws of California.Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB._SQ.FT. Date Recei t#
Z O should beconnAPPLICANT-.toth L after making Ecohis otionCertiflaleo(Fxempt the
Fshould become sobjed lake Workers'Compenutlon provlslou of the Labor TOTAL:
N
Code,you muatforthwith comply withauch provblon.,this permit Mail be
W 7 deemed revoked. DING FEE
a c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction Eendingagenry for the perform- ELECTRIC FEE
7 Z ana of the work for which this permit 1.Issued(Sec.3097,Civ.Q TOTAL:
.V O Lender's Name PLUMBING FEE B
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W d
Icertifythat l have read this app(kationard Aatethatthe above Information
a Isecom .Iagree to comply with all city and county ordinances and data laws PERMIT ISSUANCE FEES PAID:
>- relating to building ronttudi°ryand herebymthotee representatives of this
Z,
city to enter upon the above-mentioned Property for Impaction purposes. ALTER OR ADD TO MECH. Date Recei t#
_ (Wq agree to a e,Indemnify an d keep It the City al Cupertin P
against abilities,Ice onb,c.Xrol.xpenu.which may In anywayamue AIR HANDLING UNIT CFO 10,000 CFM) SUBTOTAL'
ag.lu i City I nsequenn of the granting of this permit.
AIR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTION TAX
2Z CONSTRUCTION TAX PAID:
Sign reof pp0an o OUS Date IXFTAW7 HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
WI plant ore urc ruin atom orhandle
ter9.M1a and
HEATING UMT(T0100,OJO BiI1) Date Recei t#
material as defined by the Cupertino Municipal Cade,Chapter9.11,and the
I Iealth and Safety Code Section 25532(a)2 FIG77NG UMT(OVER 108000 BTU) TOTAL: 4
❑Yes r]No
Will the applicant orfeem,bdiding occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which cent hazardous air contaminants as defined by the Bay Area Al.,
Quality yManagement Dbtrict7 BOILER-COMPpW'OR IW,IXD BTU)
Yean❑No o
7 haw read the hzzartl..oma(edab requirements manunderCM1aptcr 6.95 of BOILER-COMP(OV100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. I JUL -`
NYt
understand that if the building does nal currently have.onset,that It b my NEW RESIDENTIAL MECH. SQ.FT ^_
responsibility to notify the occupant of the rcqm
ulreents m
which most be en 091 Z
prior to Issuance of a Certificate of Onvpancy.
Owner or authorizad agent Date - )��DB���V-C7
TOTAL:
OFFICE COPY