22627 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect Identification PIi1R.9T NO.
p-u�I1Jln Address:
22627
�x Name: one: AITU<ZA FION SUBMITTAL
CITY OF CUPERTINO-BUILDING DIVISION
Con dor' N : Lie.No: APPLICATION I PERMIT
t r < <✓— / BUILDINGS•ECTRICAI PLUMBING-MFft(AMCAL CATEGORY CONTROL N
f Arc 1 ect/Engineer. Lie No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE S
LICENSED CONTRACTOR'S DECLARATION
cz
I hereby affirm that l am licensed under provisions of Chapter 9(corrreamc- APPWANCESRESSDENTIAL JOB DESCRIPTION
Ingwilh5eelon7000)of Dlvitlon3o(the Businessandl'rofeael...Code,and my 1 -
Rmese is to fall force neddied.#
Date PANES
Clan LIc.N ` 1(iV'O•tSJ Y'
Date Contracimr UP TO 200 A 9
ARCHITECPS DECLARATION 201-1000 AMPS
Occ Z rdrrstiu d my Alam shall be used u pubbe records. OVER 1000 AMPS SQ.FT.ILODR AREA $/SQ.Fr.
Licensed Professional SIGNSELECTRICAL
LED IN
Q OWNEReBUILDER DECLARATION SPECIALCEtCUIT/MLSC
IherebyafBrm tO lam exempt ER the DECLARATION
License Law for the V1 Pyjf .K•
following reason.(Secifon 70115,Business and Professions Code:Any city or C
O TEMP.METH OR POLE INST.
P4 countywhich requlmsaperMttocoesWR,alter improve,demollah,mrrepalr
Sany structure prior to its issuance,also requires the applicant for such permit to ]OWER DEVICES J DATE /Q
f5 G file a signed statement that he Is licensed ov
pursuant to the prision of the
Q6°u, Cminano/e LiceveLaw(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING LELECTRIC
�0 don3 oftheBusiness and Prameloesm
Code)orthat he is exempt therefroand VALUATION
Q the basis for the alleged exemption. Any violation of Section 7031.5 by any ^
applicant fora permit subjectithe applicant to a civil penalty of mOUTLETS not ore thanFLA ( T7 2 (�(,_W,
dollar
flue 1,as
demo thepro NEW LECTR SQ.FT. STORIES TYPE CONSTRUCTTON'
❑I,as owner o/the property,or my employees with wages as their sole
compensation,K will doBmina the work,Profen ionhe s Code::Th not Intendedodor'or ictmoffered aw
sale(Sec apply Business and f grope nes Code:The C improves Llceesn law
$ dose net apply torn owner ofproperty who nWild.morimprovssthercoRand OCC.GROUP RES.UNITS
who doessovanne ch are work
nothimself
tendedthrough hleowne.If,ho ee,provided that such Cz
improvementsarenot intended oroffered pleioe.ILhowever, flderwdingve TOTAL:
Improvement issold withlnone)mrolcomp1e11an,theavner-bupderwlll have '
tfr�ardea of proving that he did nm build or Improve for purpose ofsale.) QTy. PL BIND PERMIT FEE FLOOD ZONE APN
LJ I,as net of the property,am exclusively contracting with Banned P L IT ISSUANCE 1
l(�contracion to coestruct the project(Sec.70/4,Business and Prolamines Code:
The Cc'Imetois Liceme law does not apply to an owner of property who ALM-0DRAIN -WATER(EA)
Wilds or Improves thereon, and who contracts for such pipjects with a
TTIdon.)licensed pursuant to the Controctoth License Law. HACK FLOW PROTECT.DEVICE SUMMARY
AM exempt under See. B k P C for this reason
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
. Date RISC
EIT R
WORKMAN COMPENSATION DECLARATION ITXNRES I'ER TRAP L SCI TOOL TAX y:
N
❑1 hereby affirm that 1 have a certificatec of consent to copy
self-insure,ora a �"�x RECEIPT N
m00,Labrfifleitte ofWorkeri Compeesatlonlssuranamacertlfled copythereof(Sec. I GAS EA.SYSTEM-I INCA OUTLETS f3 PARK FEE Y N
3800,Lab C3
r
Polity N GAS EA.SYSTEM-OVER 4(FA) RECEIPT N
Com any - BUILDING DIVISION FEES
Certified copy b herebyth the cityheti. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCIIECKFEE
❑Certified copyh(Iled with the city inspection division. '
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700FT Date Recel t#
(Thissection need not be completed If the permit A forom hundred dollars
(f100)olWATER HEATER W/VENT/E.ECTR ENERGYFEE Y N
Irertlfy that In the performance o(thc work for which this permit is Issued, —
I shall not employ any person I.any manner sou to bewhi mt to the WATER SYSTEM/.TREATING
Workers'Compeesetiun Lawsof CzWornla.Date PAID
come
O Z Applicant
Z O m
NOTICETOAPPLICANT:IGrRermakingthb Certlficateof ExemPilon,you NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Fshould becoesubFat m the Workeri Cmrrgseesation probooess of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions orthis petit shall he
y deemed revoked. BUILDING
a 'c CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that them is a construction landingagency,for the perform. ELECTRIC FEE
7 Z aem.fth.work forwhichthis permit is lswed pec.3097,Civ.C.) TOTAL:
(� O Sendai.Name PLUMBING FEE
U_ Lenders Addreas QTY. MECHANICAL PERMIT {EE MECHANICAL FEE
OW Icertlfy that l havereadthb appliationand statethattheabove Information (�\j
C Rcorrect.I agree to comply with all'city and county ordlnancesand state laws PERMIT ISSUANCE 1 l^' FEES PAID:
relating to building construction,and hereby authorize representatives ofthb
N
Z city to enter upon the above.mentioned property for inspection purposes. ALTERORADDNMECH.
(We)agree to save,indemnity an d keep barMen the City of Cu pentno Date Reeei t#
V
against liabilities,pdgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City 'lnronsequenc of the an'
o(this It.-y-Zrl AIR HANDLING UNIT(OVER 10,000 CM CONSTRUCTION TAX
ignattore of Applicant/Contractor pate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATINCUMT(TO100,00011 ) Date Recei t#
matorlal a.defimd by the Cupertino Municipal Code,Chapter 9.I$and the -
Iiealthand Safety Cadei.-S�ection 25532(a)? HEATING UNIT(OVER IW,000 RTU) TOTAL-_2 s
❑ Yea u No �yry,
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) —LNY ISSUANCE DATE
which emit hazardous air contamlrunts ss defined by the Bay Area Air
as lily Management District? BOILER-COMP(3HP OR 100,IXq BTU)
yesiva 9 No
Thane read Health
a et Code,
t..2rrentsunder Chapter.1 of BOILER-COMP(OVER i00,000 BTU) Ry_
the Californiadtat if
building
Code, otcura75505,ve a tenant,
C_q°/y�/1•
ueponsindthxtn notify
thl occupant of t theentlye
meats which
that It mets my NEW RESIDENTIAL MECH. SQ.IT
role,I- llltytonisC1he occupant Ocupa rcqulrementswhkh must be met � �
prior to issuance of a Certificate of Occupancy.
Owner r authorized agent _ Data
rornL: L ISS[JED BY.
OFFICE COPY