22399 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE.BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: 22399
�-. �a
ounces-4rif one: A A
-`l—C,Q CITY OF CUPERTINO-BUILDING DIVISION
cnnt atnr'aName: Lm.No: APPLICATION / PERMIT / 1
BUILDING MECTRICALPLUMBINGMECHAMCAL CAT[GORY COMIROL a
Architect/Engineer Lk,Na:
Q ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add.: PERMHISSUANCE r � ❑ ❑
LICF.NS ED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(rommen MPLIANCESRGSIDENTIAL JOB DFSCRUTION
ingwith Secdxm700(Bof Dlvbdoo3 ofthe RuslnemaanYd ProfessioesCods,and mylicense -
s 1.full f and
ELS
Llcenscl _ p ConX.S�13 UP TO2
Date ccle_LTi Contractors, � v r -
ARCHITECT CLARATION 3014000 AMPS
ox VC I understand my plao QuIl be used as public remrda OVER IOOO AMPS SQ.FT.FLOOR AREA $/9Q.FT.
.Ob
bU Licensed Truism..) SIGNS EL �1
OWNER-BUILDER DECLARATION SPMIALC T/
�• N Ihereby afflrmthat I am exempt fmm the Contractor's Llrenee Law forlhe •I�J /yf (�CCJJ
Z O (ogowing mason.(Se tion 7W L5,Businev and Profenbna Code:Any dty or
O Z TEMP.M POLE,NST.
�Ei countywhich requtma permittocmnsttut,alter,improve,derrolbh,mrmpair
$$$ a aeystrucure prior to its iskence,alsorequlresthe applicant forsuch permit to
file a signed statement that he Is licensed pursuant to the provisions of the POWER DEVICES
Ou, Cuntractmtb License rLaw(Chapter9(commencingwithSetion70W)ofDlvl-
n SWIMMING POOL ELECTRIC
eion3 of the BusinemandPMemlons Code)mrthet he Isexempt themfromand VALVA ON
< the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLETSSWITFHPSYIXTURESL
O
applicant fora permit subjectsthe applicant to a civil penalty of not more than r I [
g� ��
$ five hundred dollars($500). NEW RESIDENTIAL ELECTRSQFP.
7< ❑I,as owner of the properly,or my employees with wages as their sale SfOWPS TYPE CONSTRUCTION
compensation,will do the work and the structure Isnot Intended or offered for
❑ sale(Sec.7064 Business and Profealoms Code:The Contractors License Law
$$ does not apply to an owner of property who builds or improv"thereon,and
who do"such work himself orlFrwgh his own emplgees,provided that such OCC.CROUP RFS.UNTfS
ImpmvemenlI are not intended oro((eredfmreale.If,however,ihebullding ar TOT L
Improvement Isold within omyearofcompltlogtheowner-buflderwlll have
t)tg.tiurden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT ---
p1.00D ZONE APN
u 1,as owner of the property,am exclusively mntrating with—.—cont
contractors to construct the project(Sec.7064,Businem and Professions Code: PERMIT ISSUANCE
The Contractor's License Law does net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EAI
builds or Improves thereon,and who comment for such piojets with a
�qOS[+tor(s)licensed pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under&e B &P C for this mason BACKFLOW PROTECT.DEVICE
QQTII�r FEES
Owner Date
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N
WORK MAN COMPENSATION DECLARATION RECEIPT.pFU(TURFS PER TRAP SCHOOLTAX Y_ N
. ❑I hereby affirm that I have o Insurance
of consent to self-insure,ora RECEIPT Y
38M,Late of Worken'Compensatlon Wurance oracertlfkN ropytFerco((Sec. GAS EA.SYSTEM-1 INCA 3800,lab C.) PARK FEC Y N
Policy X RECEPT 0
Com GAS EA.SYSITM-OVER 4(EA)
Y BUILDING DIVISION FEES
Certified ropy Is hercbyth the city city GREASE/INDUSTRL WASTE INTERCEPTOR PLAN-CHECK PEE
Bl
Cerled ropy Is(]led with the Inspection dlvlslon.
CERTIFICATE OF EttEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA 200FT Date Remi tN
(I'hlasetion need not be complied I the permit Is forces Fundred dollars
(SI0)orlema
IcerllWATER HEATER W/VENT/ELECTR ENERGYFEE Y N—
I
Nthe performance o(Ihework forwhkhthla permit le blued, —
I shall not employ any person In any manner an,as to subject to the WATER SYSTEM/TREATING
Workcm'C.�pyn Ion egl Date PAID
O Z APpllrant_( 's w ��II NEW RESIDENTIAL I'LMB. SQFI'. Date Reeel tit
Z O NOTICE TO`,GTLIC :II,aRer4rakingthla Cerliflnte of Exemption,you
should become subject to the Workers'Compematlon provisions of the Labor TOTAL:
~ y Code,you must forthwith comply with such provisions or this permit shall be :—E
G ••> deemed revoked.aO CONSTRUCHON LENDING AGENCY MIC FEE
I hereby afRmn that there Is a creatmtlon lending agency for the psrf rm� ELECTRIC FEE
Z ante of the workfor which this permit is Issued(Sec.3097,Civ.Q TOTAL:
V O Lender's Name PLUMBING FEE
LL 1- Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icedltythatl have read this applicetlonand statethattheabovelnformation
Isrorrect.l agreetocomplywithalletyand muntyordinanmand statelaws PERMIT ISSUANCE FEES PAID:
S relating to building mentrution,and herebyauthosixerepresenmtivesofthis
j— N city to enter upon the abovcre
tntioned pmpertyfor inspection purposes. ALTERORADDTOMECH.
? (We)agree to save,Indemnify and keep harmlem the City of Cupertino Date Receipt#
V against liabilities,judgments,mks and expenses which may In any wayaccrue AIR HANDLING UNIT ITO 10,000 CFM) SUBTOTAL'
ago Wtvald CillyyJln mnae9y reol the granting of this pe L
y,i/�� ///�/��— AIR HANUWNG 11MT(OVFR IO,000CFM) CONSTRUCTION TAX
Siignaturecof Applicaard/Coovttrra/tiorr I f Data EXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI tN
material as dell ned by the Cupertino Municipal Code,Chapter 9.1 2,and the -
I-Iealth and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: a
❑ Yee ri No
Will theapplicant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE REBID) ISSUANCE DATE
which emit hazardous air contamimnts i s dented by the Bay Area AU
Quality Management District? BOILER-COMP OTU'OR 100,IXq BTU) M A I
4 Y" No A
have read the ha2a nuemalerias requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building do"not currently have a tenant,that it Is my NEW ItFDFNTIAL MECH. SQ.FT. icia
respomibI ity to ntlfy the occupant of the requirements which must be met laa��as771
prior Bet; ofa Cenificat of Occupancy.
CITY Ur uurrH I INU
nerorauthorived agent to - � �
TOTAL:
ISSUED BY:� t
OFFICE COPY