22622 APv LICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Preect Identlflut PEOMITNO.
Bull ling Address: /0
9 .o L_' 22622
7 53-fC3
t-nvnerd amn ane:
Lc/}'ry �EE Zs —$�R CITY OF NPERTINO-BUILDING DIVISION
Ce^r' °r•"arae LI°•" APPLICATION I PERMIT
V/ • �'E/"�'�• BUILDINGS.ECTRICAL PUJMBINGMECIWNICAL CATEGORY CC=
Arch tett/Eagirster. Lk.No: b
h _/ TS7 Q'IY ELECTRIC PERMIT FEEBUILDING PERMIT INFO
Addrese (/O11GL E r Sl i a PERM TISSUANCE
LICBNSEDCONTRACTOR'SDECLARATION -
IherebyafflrmthatlamlicensedunderprwWonsorChapter9(mmmenc is VL
APPLIANCFSRESIDENCIAL JDESCRD'I10N
Ingwith Seebn7DOD)of Divhbn3ofthe Buslneuand Pmfneton•Code,and en
Bnnm(a In full f and effect. PANELS
License Chea_ LION I /F-IF
Date 9'_9 ssi1 Contractor
—^—TARCHITECTS CWRATI N 701.1000 AMPS
09Z0I understand my plarashall be used a a public records. OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.Fr.Q�(i Licensed Professional SIGNSELECTRICAL
< OWNER-BUILDER DECLARATION •7 l • J a-�
Fn SPECIALCIRCIRT/MISC
7 t., owing oEn.(Sect on 7 31.5,B from the d Professions
s Code:law for the
qqqqqq following motion. 7fH15,Business and Prolessiand Code:Any tlty or
Ff' c°untywhlchrequirnaperrrdtmmutmd,alter,lmpmve,demolbh,orrepalr �MP'MEI'Et OR TOLE INST.
anystmmmprbrtoi l• ame,alsorequlnstheappllnntforsuchpermltto
file a signed statement that he Ie licensed pursuant to the provisions of the POWER DCVICES
OOH Contractors License law(Chapter9(commencing with Section 7000)of Divi.
3 slon3 ofthe Business and Pef.1.raCede)arthat hell exempttherefromand SWTMMING IODL ELECTRIC VALUATION
Tithe bash for the alleged exemption. Any violation of Section 70315 by any �l �/ a L�V p U
appllmnt fon permit subjMe theappgcant to a tlWl pevlty of not more than
OUTLE755Wg1CIiFSEXTUAES L• L-t c-CJ
ofive hundred dollars($SM.
�n ❑I,as owner of the roc NEW RESIDENTIAL ELLCTRSQ.FT. STORIES TYPE CONSTRUCT ION
property,work,a or my employees with wages a•there dole
d for
e m(Sm.744,Business andwiltdothe randthes Code:rehn ontracdedorcenseLaw
Y O dale(Sec. pply to Business and Professions Code:The or improves
License law
$ don net apply torn owner of property who nemporimprovesthereon,and ITS
who doneartsamwork himselfer Nraghhis ed(mul.Ifho evert ded that Inchebuildhigor (� '
improvementsarenot Intended earofco fondle.theo v-b gofer ldbigve TOTAL: IV'
improvement hwld within he did notfcuildorlonthveforpurponsrwWhave
UT R
ttlekeSraso neerpruningof the pro dldnmbexdorlmproveracting ouof ease Qty, PLUMBING PERMIT
�uj FLOOD P
L as owner construct
the property,em exclusively contracting with Iicenssd PERMIT ISSUANCE E
contractors to is Li..the project nor apply
Business and Hof property
Code:
The Contractor's improves;
License Law don not apply e t f owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improvn thereon, and who coarses for such p(ejects with
c'ffletw-I exempt
under ant Sm
the Contractor's License Lew. BACK FLOW PROTECT.DEVICE FEE
OUSUMMARY
EFEES
L,-I I am exempt under Sec B&P C for this reason
DRAINS FLOORROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTURES TRAPPER TRSCHOOLTAX Y N
01 hereby affirm that 1 have o rertlfkam of consent to self themcf or a RECUPT N
380,Lib of Worken'Compevatlbnlmuranre cars certified copy thenar(Sec. GAS EA.SYSTEM.1 INCA OUTLETS PARK FEE Y N
3800,lab C.)
Policy N GAS EA.SYSTERECEIPTVER d(EA) RECEIPT Com anv Y�- BUILDING DIVISION FEES
Ceril/ied copy Is hereby furnished. GREASE/PIDUSML WASTE INTERCEPTOR PLANCHECK FEE '
Certified copy la filed with the city Inspection division.
CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID _
COMPENSATIONINSURANCB SEWER-SANTTARY-STORM EA.20OF'r. Date RCCeI t# a-l�
( edlon need notbe completed If the permit h brans hundred dollen
($1I or(n ortileu.) WATER HEATER W/VENT/ELFCTR ENERGYFEE Y N
Icerti(ythat tithe perfomanceaf the wwkfor which this permit le issued, —
I shall not employ any Erman in any manner so as to become subject to the WATER SYSTEM/TRPATIN'G
Workera Compensation Laweof CafBmh
o .Date PAID
z Z Applicant NEWRFBIDENTIALPLMB.__SQ.FI'. Date Revel t#
Z O NOTICE TO APPLICANT:If,after making this Certificate or Exemption,you
should became subject to the Workers'Compensation provisions of the Labor TOTAL:
V3 Cade,you It forthwith comply withsuch provision•orthh permit shall be I 4
LU > deemed revoked.
CL c CONSTRUCTION LENDING AGENCY SEISMIC FEE
NG FEE
I hereby affirm that there h a construction[ending agency forthe perform- TOTAL: ELECTRICFEE
M Z ance of the work for which this permit h Issued(Sec.3097,Civ.C.)
V Q- Landers Name - PLUMBING FEE
LL F- Lender.Addra.d QTY. MECHANICAL PERMIT "E ECHANICAL FEEas
O W Icertlfythat l have readthhapplicatlonand etatethaltheahove Information
hmrrcet.lagmetocomplywlthWtltyandmuntyardinanmaandetatelaw• • PERMITISSUANCE EES PAID:
} a relating to building construction,and hereby authorla<repmentativn of this
(— Z city to enter upon the above-mentioned property for hispectlon purposes. ALTER OR ADD TO MEDIA.
(We)agree to save,Indemnify an d keep harmless the City of Cupertino Date RCCClJ3t#
V
against llab(Iltkd,jedgments,costs a oil expenses which may in any way accrue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
afmt City in consequence ofthegra it ofthlsper it. AIR HANDLING UNIT(OVER 10,000CphO CONSTRUCTION TAX
L i 2 M10 CONSTRUCTION TAX PAID:
Slgmtumof Applicant/Contra
or Date EXHAUST HOOD M/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Willtheappe rt or Intone building occupant store or handle hanrdoud HEATING UNIT(TO 100,00,0 BTU) '
material as deflmdd by the Cupertino Muudpal Code,Chapter 9.12 and the _ Date Recei t#
Health and Safety Code Section ZS537(a)Y HEATING UNIT(OVER 100,000 BTU) TOTAL;
❑ Y. , r!No
Will the applicant or future bcilding occupant use equlpmont or device. VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hav irdous air contaminants a.defined by the Bay Area Air �®
Quality Management Distract? BOrLF.R-COMP OHPOR 100,001)BU)
T
4 Y.
havereadthehazar SusNo materialsmqulmmentsunderChapkr6.95of BOILFR-COMP(OVER 100,000 BTU) ('�
the California Health Nc Safety Code,Sections 25505,75533 and 15534. 1 OCT ! (j 1$91
understand that lithe building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT.
responsibility to notify the occupant of the requirements which must be met .city
prior to issuance of a Certificate of Occupancy. Wty of
Owner or aothorlaeagent Date V da
B TOTAL: ISSUED BY:
OFFICE COPY