2879 APPLICANT TO-FILL IN INFORMATION WITHIN RED LINES —'USE BALL POINT PEN ONLY
Building Project Identification
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22879
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CITYOFCUPERTINO-6UILDINGbIVISION
ctntradnr'.Name: Lie.Me: APPLICATION /. PERMIT-. Q'1
- " BUILDING-ELECTRICADPLUMBINGMECFIAMCAL CATEGORY , CONTROL#
Architect/Engines Lk.Nee -
{ �'�t ,.i +••t`r .,t At gyp . . -t .aI'i iBUILD�NG,�ERM1;P,INFQ"p-` ,
n , ELECTRIGPERMIT �FCB -
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Address: PERMIITISSUANCE -
LICENSED CONTRA TO �• l®
C R S DECLARATION -
- mtlnl -fC9nc-
APPLIANCES-RESIDENTIAL -
JOB DESCRIPTION
license Isle tial faceend effect. PANELS . 1 '�
License Class Lk.p _ `1 W�
Date ContractorUPT0200AWS - -
ARCHITECIPSDECLARATION - ' 2011000 AMPS
K Z I understand m Elam shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FC:
00
YP
w SIGNSELECTRICAL'
VLicensed Profeastunsl
_ ..
6 OWNEReBUILDER DECLARATION
iii�Ii3 SPECIAL CIRCUIT/MISG -
p„ Iwing atter.(Sectlam31.5,Business
he sad PrefdorbiCode:ense Law fort he - '
=ntywhichequims(Section7031.5,euslnessand Plinp ve e=re hnycity or TEmp,METERORPOLEINST.- '
ctuntywhah rryutresa permlttoconstrud alt improve,demolbh,orrcpalr '
g`'B anystrocture prior to its Issuance,also requires the applicant for such permit to POWER DEVICES
ilk a signed statement that he Is licensed pursuant to the provisions of the '
3w Contradoes License Law(Chapter 9(commencing with Section 7000)of Divi- VALUATION•
O slonli oflhe Business and Profemlom Code)orthat he is exempt therefrom and SWIMMING IDOL ELECTRIC
O 5 the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLEISSWITCHESEXTURES
applicant for a permit subjects the applicant to a civil penalty m
of not ore than
�] 'five hundred doll..($500). ��,
RG" NEW RESIDENTIAL ELECTR - .STORIES TYPE CONSTRUCTION
..p, ❑I,as owner of the property,or my employees with wager r[herr sole
compensation,Business Work,aedtheslmdureh not Intended oroffered for
' sale(Sec. pply to an
df property
Code:The Contraorimprves License Lawdoes
rj$ whodotapply torn owner ofthroug hiswho builds orimproovided thereon,and
c• who daesauchwork himself orlhrough hlsownemployees,provided that such OCC.GROUP RIS.IINCCS
Improvements are not intended oroffered far sale.If,however,the building or 'TOTAL:
Improvementlssoldwithin oneyearofcompldrogtheowner-bu8derwili have , -
t rden of proving that he did not build orimProve acting wfi.!site
se f,JTY: ) PLUIvIBING.EBRMITt- F[gpD ZANE APN
as owner of the property,am exclusively contracting with.11censed pgp�fIT ISSUANCE f
co radon to cons
the project(Sec.7044,Bursas and Pmfesvioru Code
The Comrsdore License IJw doe.ani pply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilda or Improver thereon,and who neram . for such P"cis with a a y, 1 i
' myt{actor(s)Iicensed pursuant to the Contrador'e Lkenee Law. v "'FEE'$UMMARY'("'
I am exempt under Sec .B&P C for this reason BACKFLOW PROTECT.DEVICE
OUTS]DE FEES
SANITARY Y N
Owner - Date - - _ DRAINS FLOOR BOOP,AREA,COND. -
WORKMANCOMPENSATION DECLARATION RECEIPT#pp(TURES PER TRAP - SCHOOL TAX Y_ N_
❑I hereby affirm that I have.emat(o lmurcese of consent to opy tneneo ora RECEIPT i
ce00,La eC.Workers'Compensatlonlnsurance ora certified ropythereof(Sec. , GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE ,Y_ N ,
3glic Lab C.)
I'ollry p GAS F.A.SYSTEM-OVER 4(EA) RECEI'C#
Com any ' BUILDING DIVISION FRES
ffCenlfledropybhembyfurnished, CREASE/INDUSCRL WASTE INTERCEPTOR PLANCIiECK FEE
.❑Certified ropy k filed with the city inspectlon db l.lon.'
CERTIFICATE OF FSFMPCION FROM WORKERS' - CREASETRAP - PAID
COMPENSATION INSURANCESEWER-SANITARY-STORM EA.200FT. -Date Remi t#
' (rhissection need not be completed lithe permit isfor one hundred dollars
($100)orlew.) 7
WATER HEATER W/VENT/ELFCTR ENERGYFEE Y N.
I unify that in the performance of the work for which this permit is tisued,
I shall not employ any person in any counter so ae to become subject to the WATER SYSTEM/TREATING
Worken'Compeneationl wsof Califomla.Date PAID '
O Z Applicant - NEW RESIDENTIAL PLMB. SQFT. Date Remi t# `
Z O NOTICE TO APPLICANT:[(,after making this Cedl(Icate of Exemption,you
,F should become subject to the Workers Compensation Prwisimuo(the Labor •- -TOTAL:
N Code,you=at forthwith comply with such provlsiow or this permit shall be -
W G deemed revoked. . - . - BUILDINGFEE
1CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirm that there Is a construction lending agency for the perform ELECTRIC
7 Z ance ofthework forwhlchthfe permit lC leaned(SL ec.3097,Civ.C.) TOTAL: `
()O' fenders Name - - 3 �, PLUMBING FEE
ly F Lenders Address QTY. " .MECHANICAGPERMIT [FEE' MECHANICAL FEE
OW I certify thatl have readthis application and statethatthe above Information -
,a is correct.l agree to comply with all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID: ,
} relating to Wilding construction,and hereby authorise representatives of this -
H Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH. Date ROeei t#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino P
against liabilities,I.dgmenls,consand expense.which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said Cl consequencamthegramingofthl ermit .,
/40. - A[R HANDLING UM T(0VERI0,(F0CFM) CONSTRUCTION TAX. '
Igna mr pp ant/ omractor Date G EXHAUST HOOD(W/DUCT) - - CONSTRUCTION TAX PAID:
HAZARDOUS ERIALS DISCLOSURE ' . '
Will the applicant or(uture building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)' Dale PRfCeI t#
material 5s defined by the Cupertino Municipal Code,Chapter 9.12,and the
Ikalth and Safety Code Section 2S532(a)?' HEATING UMT(OVFS 100,000 6TLB 'TOTAL:
Ye. M No
Will the applicant or future buildimi'mcupant use equipment or devices VENTILATION PAN(5INGLE RESID) - ISSUANCE DATE
m. which emit hazardous air coma minants as defined by the Bay Area Air -
Quality Management District? BOILER-COMP OHPOR 100,000 BTR)
n❑Yes ❑No /f �' r Ihavc read the hazard. maicrials requlretnents under Chapler6.95 of BOILER-COMP(OVER 100,003 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.,1
understand that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MF.CH. SQ.FF - Jg
respoosibiity to notify the occupant of the requirements which at be met .\
prior to issuance of a Certificate of Occupancy, v�
Owner or authonzed agent - Date" ISSUED BY
' TOTAL:
OFFICE COPY