22228 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
-
Building Project Idemification - PIRMITNO.
Building Address: - 22228
7^^ 17n
11h
»•ner. sine: 414 ae. CITY OF CUPERTINO-BUILDING DIVISION
c°mrador.Name: - Ile,No, APPLICATION / PERMIT
rchitect ' ginee �Tl
iAJ ' 3U Lic.No:
TlA
BUILDINC-ELECTRICALPLUMBING-MECI IANICAL CAIRY CONTROL
Ar.
•ELECTRIC PERMIT tI� 1'FEE )BUILDING PERMIT INFO
Address: I _ ga. - V PFRMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions ofChapler 9(commenc APPLIANCES-RESIDENTIAL - ' JOB DESCRIPTIONIngwlth Section 7000)of Dlvtsian3 ofthe Bminessand ProfesslonaC„ode,and my
license is In full forceand'effect. PANESc
Li esc CLien_ Contin 3CsI')4C. {J
ur UP TO 200 AhVS
ARCHITECT'S DECLARATION 2014000AMPS
07C0. ]understand my plawshall tie used mpubllcremrds. OVLRIOW AMT'S - SQ.Fr.FLOOR AREA 5/SQ.FG
�GG U Licensed Professional SIGNSELECTRICAL A'A D
OWNER-BUILDER DECLARATION SI'ECGLCIRCUIT/MISC t
IN
Ihereby affirm that l am exempt fromthe Contractor's Ucenss Lawfnrthe -
pp following reason.(Section 7°31.5,Business and Pmfeaslans Code:Any city or p�
OZt:� TI
following OR POLE INST. P K
r4 � countyw mpdroto Its pertNttomrotequireser,the apmvgdennlbh,ormpair
mitI
any atrudurepdement that
he h,also sed pursuant t the provisionorsuch s
of permit POWER DEVICES ry
p file a signed statement that he b licensed pursuant to the provblov of the Lb go
pgg,,Ok Contractors License Law(Chapter 9(mmmencingwith Section 7000)ofDivi.
F,�03 sion 3 ofthe Business and Professboru Code)orthat he b exempitherefromantl -` SWIMMING POOL ELECTRIC ,
yy@ the basis for the alleged exemption. Any violation of Stolon 7a11.5 by any
applicant for a permit subjeciathe appilcant to a civil penalty of not more than OUTLETS-SWITCHES-FIXTURES Q�
five hundred dollars($S _ NEW RrMDENITAL ELECTR_SQ.I7,
OI,as owner of the.property,or my employees with wages as their sole STORIES TYPE CONS7kI1CTION
compensation,will do the work,and the structure Is not Intended or offered for
O sale(Sec.7044,Business and Pmfemioro Code:The Contractor.Lt..Law
$$ does not apply to an owner of Property who builds or improves t hereon.and OCC.GROUP RFS UNITS
whodoe...ch work himself or through his own employees,provided that such
improvements are not Intended oroffered forsale.If,however,thebuildingor TOTAL:
improvement baold wlthinoneyearofcompletion,theawner-bullderwill have -
th&f,rden of proving that he did not Wild or Improve for purpose of sale.). QTY.'" PLUMBING PERMIT ' FEE IT.00D PDNE •APN
a.owner of the property,am exclusively contracting with licensed pppp ISSUANCE
contractors to construct the project(Sec.704k Business and Professions Code:
The Contractors 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 ptatects with
cga4actor(s)licensed pursuant to the Contractor.License Law. 4 BACK FLOW PROTECT.DEVICE 'FEE SUMMARY t,'•
LJ 1 am exempt under Sec &P C for thin mason
Owner Data DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y— N—
RECEIPT 0
WORKMAN COMPENSATION DECLARATION
❑I hereby affi m that 1 have a cenFIXTURES-PER TRAP SCI IDOL TAX Y— N
ifleste of consent to self-Insure,ora RECEIPTNM
381111,Lab C.)-
cenlflcateofWorkeri C.Pevallaninsurenceora.difk .mpythemof(Sm. GAS.EA.SYBTEAI-1 INC.40[TILEIS PARK FEE Y_ N_
'
CoPol
N.
m an GAS EA.SYSTEM-OVER4(EA) BUILDNGGDIVISION FEES
enl0ed copy b filed
dwfurnished.hthcityGREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
❑ rtland copy is hereby hcity lvpectlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE + SEWER-SANITARY-STORM EA 200FT - DBte RCCCI IN
(Thissection need not be completed lithe permit b for orae hundred dollars
($1I cemlca9.) - WATER IIFAI'ER W/VENT/MrCTR ENERGYFEE Y N
I cent em t o the person in an tmannerhework sufioas to become
b bo theed, — —
I shall not employ any person In any manner m as to become subject to the TER SYSTEM/TREATING
Applicant s'Compensatlon Gws o(Gilfornla.Date WAPAID
O Z - NEW RESIDENTIAL PLMB._SQ.Fr. Date Recti tN
Z NOIICEoome subject
to
orker akingthbation caleof Exemption,you
should dc,you=atforthwith
the Work en'such provisinpmvlamuo it.h.11he be TOTAL:
� W Code,drevoeforthwith comply with each provisions orthb perMtshallbe BU NG ' oda
j deemed revoked. '
IL0 CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there is a coratmetion lending agency for the perform ELECTRIC FEE
7 Z ante of the work for which this permit is Issued(Sec.3097,Civ.C.) TOTAL:
02 Lendcr,NamePLUMBING FEE
LL H lenders Address QTY. MECHANICAL• IIRMIT' FEE MECHANICAL FEE
OW _ Icmilfythatlhave rcadthbapplication and&mathettheaboveinformatlon
4 Isco.rect.I agree to comply with all dty and county ordinances and slate laws PERMIT ISSUANCE FEES PAID:
} reliy�hg to building construction,and hereby authorize representatives ofthh%
F U) cityiaenterupon the abovcmentlorud property for inspection purposes. ALTIRORADD'11OMECH. - Dale RCCeI
— (We)agree to mve,Indemnify and keep handed the City of Cupertino - Ptk
against llabilltles,judgments,ends and expenses which may In any wayacerue AIR HANDLING UNIT(DO 10,000 CIM) - SUBTOTAL:
aga mt said Ctry In consequence of the anting ofthi.permit.
s-4 AIRHANDLING UMT(0VFR10,=CFM) CONSTRUCTION TAX
bgnature of Appicant/Contractor .. Date D(HAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARDOUSMATERIALS DISCLOSURE
Will the applicant or future building omtpam store or handle hazardous HEATING UNIT(TO,100,000 BTU) DBIc Recei IN
material as defined by the Cupenlno Municipal Code,Chapter 9.12 and the -
HeaRh a.d Safety Code Section 25532(x)? HEATING UNIT(OVER I W,000 BTU) TOTAL:
❑ Yes r]No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) IS. A,NCE DATE'
which emtam
it hzmrdou.air contaminant.a.defined by the Bay Area Ali �r
Quality Management District? - MOILER-COMP(3I'B'ORIOg(XUBT )
4 Yes No
have read the hazarousmaterials requirements under Chapter 6.95 of BOILER-COMP(OVIR I W,000 BTU) ' tfi0
he California Flcalth&Safety Code,Sections 25505,25533 and 25534.1 9
understand that ltthebuildlngdooscen mrrentlyhaveatenant,that it ismy NEWRESIDFNIIALMECIL SQ.FT. d1z.
respoto Issu Issuance
of a Certificate
of Ocftherequlremenb which nwst be rrct
napoasbivance notify
cau ofOmpa reqs
Owneror authori,redagent Date . \�, \
" TOTAL: 755UEDBY:y_ ✓i'�V'�V`
OFFICE COPY