22532 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
stdln Project identification PERMIT NO.
Building Addres
- 22532
a one: _
e'i, CITY OF CUPERTINO-BUILDING DIVISION
. c°n a ;•Nana: LIc.Na APPLICATION I PERMIT -1
BUILDINGELECnUCAI nUMBING-MEC}UMCAL CATEGORY CONTROL M
Architect/En neer. Lic.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: e ' MI
PERTISSUANCE ❑ ❑ ❑
LICENSED CONT CTOR'S DECLARATION
Ihembyaffirm thatlambcensed underprovislonsof Chapter9(commm APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Setion7000)of Di odkr3ofthe Buseessand Proksal...Code,and my
ficer.jAm fun force end effect. PANEL"
ontr ctor 5/
Date Contnd°r MI'S
ARCHITECTS DECLARATION 701-1000 AMPS
ss0 2 I understand my plans shall be used as public records. OVER 1000 AMIS SQ.FF.FLOOR AREA §/�.ET.
COC
U Licensed Professional SIGNSELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/MISC
2 7� IherebyafRren that amexempt from the Contractor's License U.for the
pp following reason.Section 74015,B.M..and Prokaskus Code:Any city or
�2F. ro
� untywhich rcw
qulresa pemdt/omrut
t ,alalter, m
Improve,deoWh,orrepalr TEMP.METER OR POLE INST.
nystmture prior toile Issuance,also requlrestheappllcant forsuch permit to POWER DEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
Contractors License Law(Chap[er9(romntencing with Section 70W)ol Divl- SWIMMING POOL ELECTRIC
SOS sko3oftholhudeem.rd Profeadmo,Code),rthe he b exempt there(romand VALUATION
tZ
S" the basis for the alleged exemption. Any violation of Section 7031.5 by any
OUTLETS-SWITCHES-FIXTURES 800.CW
<.e
applicant furs permit subjects the applicant to a civil penalty of no more than
fiF11,ave hundred
owner of the property,
NEW RESIDENTIAL ELECTR SQ.FT, STORIES TYPECONSMUCTION'
<n ❑Lasownnro(othe work,and
my employeawithended ffamdfe
compensation,Businesaworkandthes Code: Vnotintendedorofferedfor
O ale(Sec.7094,Business and Profeeebre Code:The Conlratofs Llcewe Law
p S s does not apply to an owner of property who builds or Improves thereon,and OCC,GROUP RES.UNITS
who does such work himself or through his own employees,provided that such
improvements are not intended oroffered forsale.If,however,thebuilding or TOTAL:
improvementewld withinoneyearofcompleliogthe owner-bullderwillluve
t rdenof poving that he did not bund or Improve for purpose oink.). QTY, PLUMBING PERMIT FEE
Lj L as owner of the property,am exclusively contracting with licensed WOODT�NE APN
contractors to corotmd the project(Sec.7014,Business and Professions Code: PERMIT ISSUANCE
The Contr Ickes Lkense Law does rat apply to an owner of property who ALTER-DRAIN&VENT WATER(EA)
buikis or Improves thereon, and who contracts for such piptet - -
s with a _
��78_t[act (•)IlwnxdpunumtWthe Contradoe.License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
L,J I am exempt under Sec B k P C for this reason
•
DRAINS-FLOOR ROOF,AREA,OOND. SANITARY Y N Owner Date RECEIPT
WOR KMAN COMPENSATION DECLARATION FIX'IVRF_S PER TRAP SCHOOL TAX Y N_
QI hereby aBlrm that I have o certlBate of consent to opythenrc,(S a RF-CEII'f M
crutifi3800,abte of Worken'Compematlon Wurance oracerti(led copythereof(Sec. GAS EA.SYSTEM-1 INCAOVILEFS PARK FEE Y N
PolPolk Lab C.)
Cffi GAS EA.SYSTEM-OVER 4(EA) BILI'T q
Cam any BUILDING DI VISION FE ES
[jCertRed copy is herebyththe city GREASE/WDUSML WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V filed with the city inspection division.
CERTIFICATE OF IXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATIONINSURANCE SEWER-SANITARYSTORM EA 700FF Date Recei t#
(This setlon need rat be
COMPENSATION
SURA b Ionone hundred dolian
($100)arlessP
I certify that the performance nabs work for which permit is Ito —
N
I shall not employ any person in any manner w u to become eubjed the WATER HEATER W/VENT/ELECTR ENERGY FEE Y to the WATER SYSTEM/TREATING
Workers'Compensatlon Laws of Gll(omfa.Date PAID
ZQ NOTicant
]ETO APPLICANT:](,ager making this Certifiateof Exemption,you NEW RESIDENTIAL PLMIL SQFT. Date Recei t#
Hshould bemmesubect to the Workers Compensation provisions ofthe Labor TOTAL:
N Codpyou moat forthwith comply with such provisions orthis permit shall be
j deemed revoked. UTNG
ECE
LU
C CONSTRUCTION LENDING AGENCY SEISMIC FEE e
I herebyalflrmthat there is a construction lending agency for the perform, ELECTRIC FEE
Z anceoflhe workforwhichthh permit V Issued(Sec.3097,CIv.CJ TOTAL: s '�
V O Lender's Name PLUMBING FEE
IL H Lender'.Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O O l certify that l have madthi.appliatkr..d ststethetheabove information
Isrorret.I agree to comply with all city and county ordinances and pate laws PERMIT ISSUANCE FEES PAID:
} IL relating to building construction,and herebyauthoriza reprexntativesofthis
zcity to enter upon the shave-mentioned property for kspedlon purposes. ALTERORADDTOMECH.
(We)agree to save,indemnify au it keep harmless the City of Cu Fenton Date Receipt#
V against liabilities,Pdgment•,casts and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CEM) SUBTOTAL'
ago Inst said City In consequence of the vntingof his permit.
/J 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
(" /
Signatureof AppOcq� Contractor Date EK}fADST}IDDDIW/DIKT) CONSTRUCTION TAX PAID:
HAlABDOUS MATERIALS DISCLOSURE
Will the n deflukantore urs ruin ngonvpantstore Ch pier handle 9.hazardous }(EATING UNIT(TO I00,000 BTU) Date Recei t#
Healthal as defined by the Cupertino Municipal Code,Chapter 9]k and the
Health and Safety Code Section25532k)? HEATING UNIT(OVER 100,000 BTU) TOTAL:
Yea No
Wi ounit haeardntor trnuandidingmceflue bythe Bayequipment Area
devices VENTILATION RAN(SINGLE RESID) ISSUANCE DATE
which emithazardousairrict? nb as defined by the say Arca A4
Quality management IXaWt7 BOILER-COMP(3}E+DR 100,000 BTI]) P
4Yes n�J No
have read the huaidoasmd.dab rcea ons 2555,2553 and 2S534.
of BOILER-COMP(OVEt 100,000 BTU) UG the Gitfomlalt Ifleathe
k afetybuilding
Code,not
entlyh have
ate ad755at It f9r�
understand thatIfnotify
the occupant not the
haves which
that be I.my
NEW AGSJDENTIAI.MEGA, 5(j.Ff. �QQ
prior
responsibility to ramify the occupant of the requircmente which must be met TYII�
prim to issuance of a Certificate of Ocavpancy. /4h'VOf Cu
Owner or aulhmired agent Data
ISSUED BY
�s��
TOTAL:
OFFICE COPY