22235 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PFaKONLY
Building Pro en Identification PIRMITNO.
OuOding Address: ^2 2^r/
IR44`7 P2J�E..121P GE GGGISI eI"/F
wnen ams: dd one:
—PRCA42 4i" �dS 3'O CITY OF CUPERTINO-BUILDING DIVISION /� �
Cr,arc°/1eNe6" / Lic'No: APPLICATION / PERMIT (�
�C -11
2s.1 WCtU I� NL[.YLC'NGL�7' L S V3 / BUILDINGELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROLa
Architect/Engln�epr. - Lk.Nce.
A E�sC QTy ELECTRICPERMIT FEE BUILDING PERMIT INFO
Addreea: l�q- '1 'I, JtJ�EQ,IU PERhanSSUANCE '�,CidISI
LICENSED CONTRACTOR'S DECLARATION aS
I Mroby affirm that l am licensed under provisions of Chapter 9(commene- APPLIANCES-RESIDENTAL ]OBDESCKErH0N
Ingwitties.hSM un forces Division fect. fthe Buslnemand Profee.lon.Code,and my ^
license Is I.ie!u0 torte and icc.sl PANELS �d Vk 1✓II OF—
LlanseClaes Cordy
Date Conlnctor
_ UP TO 200 AyU
ARCHITECPS DECLARATION 12014000AMPS
9z ants m lane as pubecremrda OVER10DOAMPS SQ.FT.FLOOR AREA S/SQFFT.
U 00
LI sed rofese ovlSIGNS ELECTRICAL A L E D 1
1L�7 OWNER-g NLDER DECLARATION SpFGGLCIRCUIT/MLSC
z a I hembyafOmn that Iaro exempt fromthe Contractors Limnse Law for the M P T E
Q following reason.(Section 70315,Business and Prefeasbns Code:Any city or
F H� county which requirma permit tocorc
rutru ,alter,Improve,cieseehoh,ormor TEMP.METER OR POLE INST.
anystm=mpdortoltslamame aleorequimstheappliantforsuchpev tto // � '
O file a signed statement that he V licensed pursuant to the provisions of the
POWER DEVICES
w� DA E
Conmo or's License,law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
SOS slon3 ofthe Business and Profeadoru Code)orthat he Is exempt therefromundpermitthe basis for the alleged exem"n. Any violation of Section 70315 by any
<� applicantfora permit subjeciatheappllcantloa civil perultyof no rremethan OUTLETSSWITCHMFIXTURES
five hundred dollars(SSW),
E]1,as owner of the property,or my employees with wages as their sale NEW RESIDENTIAL ELECTRSQ.Fr. STORIES TYPE CONSTRUCTION
acompensation,will do the work and the structure is not Intended or offered for u"hI-'« tea{ (Qxco
❑ sale(Sec.7044,Bagneas and Pro(esal..Code:The Contractors License Law
does not apply to an owner ofproperty who Wilds or improves,thereon and OCC.CRO(11a REB.UNITS
who docesuchwork himself orthrough hie own employees,provided that such
improvements are not Intended oroffered lorsale.If,however,thebuilding or TOTAL:
Improvement lasold within oneyearofcompletlon,the owner-bullderwiil have
tl�urdcn of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APNr
LJ L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE r"1 if-1
contncters to construct the project(Sec 7044,Bu.ineas and Pe de alms Code: 4 L.1✓
The Contractor's License Law does no apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p(oisos with a
c7ilgactor(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
L t 1 am exempt under Sec B k P C for this mason BACK FLOW PROTECT.DEVICE
DRAINS FLOOR ROOF,AREA,COND. `�,ov SANITARY Y N �_Owner Date RECEIPT N
WORK MAN COMPENSATION DECLARATION FIXTURES PER TIAP SCHOOL TAX Y_ N_
❑I hereby affirm that I have o Insure to of consent to self-instme,ora RECEIPT N
MOO'certificateolWorkers Compensatlonlnuuranreonrertifled copy thereof 'GAS EA.SYSTEM-]INCA OUTLETS PARK PER Y N
3Nlq,Lab C.)
Policy N PT
GAS EA.SYSTEM-OVER d(EA) DING DI N
m BUILDING DIVISION FEES
CediBed copy is hereby famished. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECK FEB
EM led copy la filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASETRAP PAID f�
COMPENSATION INSURANCE SEWER- STORM-S[ORM EA.1WFf. Date Remi t# �3
Hhisseetion need not be completed Ithe per lit is forone hundred dollars
(Si W)oIrertify fh laaWATER HEATER W/VENT/ELFC'I'R ENERGYFEE Y N
thkt the perforrtunufthe work forwhlch this pennitblawed,
I vhaR not employ any person In any manner eo n to became subject to the WATER SYSTEM/TREATIN'G
Worker Compensation Laws of California. Date PAID
—
Z Z Applicant - Date.
Z O NOTICEco MPLICANT:e, orloars'Com er ationlnteof Exemption,you
king NEW RESIDENTIAL PLMB._SQ.Fr. Remi t#
H
should ode,yo at
thwitect the Workers'Comprovionprovisions
permit
the Labor - TOTAL:
N deemedunwetforthwith comply with such proWbru orchis perMtshall 4 UI 1
deemed rooked. ✓1
so
aC CONSTRUCTION LENDING AGENCY SEISMIC FEE 00
Z IherebyafNmthat there is a construction lendingagenry,for the perform TOTALo ELECTRIC FEE
anre of the workfor Which this permit's Wued(Sec.3097,Civ.C.)
V O Lenders Nara PLUMBING FEE t a
LL l— Lender.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEB Cab
O W. Iartlfythatl have read thlaapplicatl°nand statethattheaboveinformation
is,mourrect.Iagreelo comply with ail city and county ordinances and gate laws PERMIT 2r FEESPAID:
} 1 relating to building construction,and hereby authorize representatives of this
[— NCity to enter a Pon the above-mentioned property for lmpection purposes. ALTER ORADDTO MECH.
? (We)agree to save,ledemrdty an d keep harmlem the City of Cupertino Date Receipt#
V agalreollabillties,jrdgmen1s1 meta d expenses which may In any way accrue AIR HANDLING UNIT CTO 10,0°0 CFM) SUBTOTAL:
agal stsaid ity m em sequen a gra acing of this permit.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
; natures Oran ontmator Date E(HAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
H RDOUS MATE ALSDISCLOSURE
Wlllt cseptimntorfuture building ocavpant store or handle hazardous HEATING UNIT(TO,100,000 BM Date RCmi t#
material as defined by the Cupertino Municipal Code,Chapter 9.1Z and the
Health and Sdety Code Section 7553I(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL' s
❑Yes r!No
Will the applicant orfutum building occupant use equipment ordevices VENTILATION FAN(SINGLE RESID) ANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP OHP OR 100,000 BTU)
4 Yes Na
haveread Healthe h
a Safety
Code,Se reons 255 5,2553 .Chapter.1 of BOILER-COMP(OVERIW,(Kp BTU) Ai uQ
the Caltandt acute dr building
Code,Sections have a tenant,
that
/ v e
understand that lithe the occupant not erequire encs tenant,that b met NEW NESIDENI7AL MECH. SQ.Frrespon
priors hatuability c notify the ocmpantofthe requirements which must be met ✓!R ��W
prior to lssuanrn ofaCertlfiate of Occupancy. � "�j0.7 --��
Owner or authorized agent Date 1 ���-4�^''�
TOTAL: .J7 ISSUED BY\ \ /:
OFFICE COPY