22605 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Address:
i u/yetwzc- 4nc 4L. API?UCAMWMW2MT2M6=0
nera amu: 4S.y�e^ez
I,L 66(' 7(/+ CITY OF CUPERTINO-BUILDING DIVISION
qC
pntractm'.yams: LiC.No: APPLICATION / PERMIT b
,Archil Engl r. I No: BUILDING-ELECTRICAL PLUMBING-MECHANICAL CATEGORY CO
, /, 'ACJE'Ati� BUILDING PERM
QTY ELECTRICPERMIT FEE
Address PERMITISSUANCE F-1 ❑ El
CONTRACTOR'S DECLARATION
I herseett.lnnthatlem lkrn3.fthunder provisions Chapmn9de,and c- APpIJANCESRE5IDENRAl JOB DESCRIPTION
[I ..1.1.fell 7000)on DlWfect. ([he Buelnexand Profes.lone Code,and my
Lt...sin tali roe and effect. PANELS
Limnx Gla Llc.pSjS9�_. 1.3
Dat ontnRor_"ya-y,��_ UP TO 200 AMES
ARCHITECPS DECLARATION 201-1D00 AMI'$
0 I understand my plaraehall be used as public records. OVERIDOOAMPS SQ,FT.FLOOR AREA S/SQ.FT.
Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION `JL/
rug SPECIAL CIRCUIT/MLSC
Z Iherebyaffirmthal lam exempt from the Contractor's License Law for the -
fouowing reason.(Sedi.70315,Bueinenand Profmlons Cede M d or
Fa' county which requbnapemdt toronsWct,alknlmpmve,demolish,orrepalr T12AP.M=OR POLE INET.
anystructure pdorto its Issuancs,•isorequirmthe epplicantfor such permit to OWER DEVICES
O file a signed statement that he Is licensed pursuant to the provolons of the
av Croract.e.License,Law(Chapter 9(commencing with Section 7000)of Divi.
.OS Aon3ofthe Bus(nessand ProfewWmCode)orthat heboxempttherefromand SWIMMING POOL ELECTRIC VALUATION
the basis for the alleged exemption. Any violation of Section 7011.5 by any
appnont for a permit subjects / 1 �eY
< Nthe applicant toe civil Penalty net more thin OLTTLETSSWHCHESFIXURES — `I
❑ V00
five hundred dollen(5500). -
I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELEC M TYPE CONSTRUCTION
mmpensflon,will dothe work andthe structure is net Intended or offered for
Osale(Sec.7040 Business and Predenloru Code:The Contractors License Law
S2 does not apply to an owner of property who Wilds or Improves thereon,and CiFGMF
OIT UP RFS.UNITS
doesaucb work himaelforthrough hlsown employees,provided that such / r
Improvements are not intended oroffered forsale.If,however,thebullding or noffTAL: f
Improvement usold wlthinoneyearofcompletion,theowner-bullderwill have f
II)gkuNen of proving that he did not bund or improve for purpose o(aale.). QTY, PLUMBING PERMIT FEE
u FOOD 7DNE ArN
4 as owner tr the property, Se exclusively Busi contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Professions Code:
The Contractors License Law does net apply to an,owner of property who ALTER-DRAIN&VENT-
bunds or Improves thereon,and who contacts for such with a WATER(EA)
mp4actm(s)licensed pursuant to the Contractors Llcenx Law FEE SUMMARY
Ll I am exempt under Sec. B &P C for this mason BACKFLOW PROTECT.DEVICE Frrq
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N
. Owner Date RECEI'f If
WORKMAN COMPENSATION DECLARATION FIXTURES PER TRAP SCHOOL TAX Y N
01 hereby affirm that 1 have a certificate of consent to xI-Insure,ce a RECEI7 M
cenificete of Wmrken'Compensationlnsunna era cerifed copythereof(Sec.
3800,Lab C.) GAS FA.SYSTFM-1 INCA OUTLETS PARK FIT Y N
Policy Y REC Fr p
GAS ESVSI'Od-0VFR 4(FA)
Com aBUILDING DIVISION FEES
CertiA.
ny fied copy is heed with he city CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
odlfied copy is filed with the city inspection division. /v�sk J
1 CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP V•-16�� 6.2
COMPENSATION INSURANCE PAID J L 11Q
(Thlsunlonneed not becomplemd lithe permit isforom hundred dollars SEWER-SANITARY-STORM EA.200FT. Date Recei t# `t/4
(5100)arler.)
00).r lythat in the performance o(the work forwhich this penult is Issued, HEATER W/VENT/ELECTR ENERGYFEE Y— N—
I
—I shall not employ any person In any crammer so as to become subkct to the WATER SYSTEM/TREATING
Workers'Compensationlews of Cali(mnh
O Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date Recei til
Z O NOTICE TO APPLICANT:If,after making l his Certificate of Exemption,you
should become subject to the Workan'Cempenwt ion provisions of the Labor TOTAL:
W
Code,you=at fnt hwlth comply with such provisions or this permit shall be BUILDING
W > deemed revoked.
IL G CONSTRUC ION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a construction lending agency forthe perform- ELECTRIC FEE
M Z armoftheworkfor which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
U O fender.Name PLUMBING FEE
IL I— Iendse.Acidreo QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1cedlfythatl have rconadthisapplicat( cad mate thatthe above Information
6. nomme.lagmetommplywithaBdtyandcountyardInancesand Yatelaws PERMIT ISSUANCE rEESPAID:
r relatingtobullding construction,and hemby authorize representatives ofthis
H 2 City to enter upon the above-mentioned property(or Impactor,purposes. ALTER OR ADD 7O MECH. Date Recel ted
V — (we)agree to save,Indemnify an d keep harmless the City of Cu Pont.. P
agabut lisbl xpenses which may In anyw yaocrue AIR HANDLING UNIT(170 10,1100 CFM) SUBTOTAL:
told n en oft Ung III horernn .
AIR HANDLING UNIT(OVER IO,ODOCFM) CONSTRUCTION TAX
Sig®tare.(Ap cent/Contnctar m EXHAUST HOOD(V9/DUCT) CONSTRUCTION TAX PAID:
HA 1t"USMATE LS DISCLOSURE
Wllliheapplies t or future building pant store or handle hazardous HEATING UNIT(TO 100,000 BTT) Date Recel Ill
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and SafetyCode Section75532(a)7 HEATING UNIT(OVER 100,000 BTU) �r Lt G
❑Yo No
Wllltheappheant or M building.pant..eequipmentordevices VENTILATIONFAN(SINGLERESID) DAN( yDE�ATE
mi
which et hazardous air contaminants as defined by the Bay Area Air 7 T IOg,
Qua Management District? BOILER-COMP OHP OR 100,007 BTU)
7
4 Yes No
have read the haza ousmatcrials requirements under Chapter 6.95 of HOMER-COMP(OVER100,DDO BTU) M�M�
the Ca111amia Health&Safety Code,Seccmsntly have
a tend,that I W a/I
respordtonsibility
that If the notify
the ing occupant of the requirrostotsw which
that ltismy NEW RESIDENTIAL MF.CH. SQ.FT
resportsiblllty to natty the occupant.(the requirements wMch moat be crM
prior to Issuance of a Certificate of Occupancy. TS
Owner or authorized agent Data - ISSUEDBYJ
TOTAL:
OFFICE COPY