22078 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
Building Protect Identification PERMIT NO.
Rullding Address; - 22078,
ne a antra: one:M ,,../
0T/ � -
E►a ►�� Zs CITY OF CUPERTINO-BUILDING DIVISION r y a
coetractrra Namc: LION°: APPLICATION it PERMIT
o W tIxj C rz , BUILDING-ELBCTRICAI PLUMBING MECHAMCAL CATEGORY CONTROL N
Architect/Engineerr,
Le,No:
- �QIY ' ` .1 -t ELECTRIC PERMIT +1" ',IPEE '- �:aP�igBU[LDINCPERMLT INFO
Address: I PERMIT ISSUANCE `�(.�• I�GI � �[1 MUC
LIC(iTR
NSEDCONACTOR'SDECLARATION ' - tt LS7 L7
T hereby affirm that lam licensed under provblonaof Chapler9(rommenc- APPUANCESRESIDENIAL JOB DESCRIPTION
ingwhhSectlon force and affect. rfthe Buslndsand ProtesslonsCode,arae my -
license Iain(uV force and effect + PANELS
Licenu Cbss Llc.p
Date Contractor '
ARCHITECT'S DECLARATION, 201-1000 AMTS
OZ (understand my pbnsalull be used as pubtic records OVERT WOAMPS LSQYf.y�RA'I?� S/SQ.FT.
O CCE
K Licensed Professional. S GNS ELFOTR CAL u T E R
�z OWNER-BUILDER DECLARATION S['ECIALC]RCUIT/MISC
Z t.,M2 (hereby affirm that lam exempt the Contractor's License Law for the
O Z•'
oo following reason.(Sectlon 7031.5,Business anro
d Pfesson Any city or
Code:ATEMP.METER OR POLE INST.
P4
any which
require,.permit toconstrect,ce,.be,req.(alter,the aprovgdemsuch,rtcrett 7J
� any awdum pate tent that a is abo sed pursuant
uant t the provisions
inions of t e `,TOWER DEVICES
file a signed statement that he b licensed pursuant to the provhions of the _J
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
slon3o(lhe Business and ProfmlonsCrde)orthat he Is exemptthertlromand VALUATION
ad
the bash,for the alleged exemption. Any violation of Sectio7031.5 by any s OUTLETSSWITCHESFIXTURES 2x,v '(JQQ.
applicantfora permitsubje theapplicanttoacivilpemhyofnot nnrethan t
five 1,as
demodollarthe'10_,� NEW RESIDENTIAL ELECTR_SQ.Ff. STORIES TYPE CONSTRUCTION
I,as owner o(the'p work,a or my employed with wages r thele sole
��11 compensation,willdoth.work,andthestwctc:TheCintendr'orcense Lw -
O sale(See 7Ba4,Business and Professlom Code:The Contractors Llconse Law
dodnotapply to an owner ufpropeitywho builds or lmprovdthemoR and. OCC.GROUT' RES.UNITS
0.0. who doessuchwork himself°rlhrough hisownemployees,provided that such
improvements arc not Intended Droflered formic.If,however,thebuilding or TOTAL: I LtS
\
Improvement bsoldwithlnomyearofe mpletion,the owner-bulWerwill have
f1d. n of proving that he dies net build or improve for purpose of sale.). QTY, PLUMBING PERMIT', "FEE' FLOOD ZONE APN
s owner of the property,am exclusively contracting with licenses PERMIT ISSUANCE
.to construct the project(Sec.7044,Business and Professions Code: 1.Cc
ractor'.License Law does net apply to w owner of property who ALTER-
Improves thereon, and who contracts for such pojecta with a DRAIN&VENT-WATER(EN(e)hcensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE=SUMMARY
exempt under See. B k P C for this reasonOUTSI
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N�
FEES
Owner Date RECEIPT p
WORgNAN COMPINBATIDN DECLARATION pLXTUREq ppR.I.RAI' (D SCHOOL TAX Y N
❑I hereby affimorkem that I have o 1.2'a of consent w self-inwre,ora RECEIPT N
certl0cate bC.) rkers Compensationlnsurance rracerti(led copy thereof(Sec. GAS FA.SYSTEM-1'INCA OUTLETS PARK FEE Y N
Polis Lb C.)
'C5C GAS F.A.SYSTEM-OVER 4(EA) DING rDIV
Cam any tlU1LDING DI VISION Fr.ES
copy's therebyfurnished.the city - CREASE/1NDUSTRL WASTE INTERCEPTOR PLANCI'IECK FEE
�Certitled<Opyb(Iled with the city inspection division. -
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID -
COMPENSATION INSURANCE
(Thlssectlonneed notbecomplated ilthepermlt bforom SEWERSAFIITARY hundred dollars STORM G,2WFT. Dale Remi t#
(S10O)orlem.) WATER HEATER w/veNT/al[cTR ENERGYFEE Y N
I cattily that In the performance of the work forwhich this permit Is Issued,
I shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREA77NG
Workers'Compensation Laws of California. Date PAID
0 Z Applicant
Z O NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you NEW RESID=- AL PLMB. SQ.IT. Date Recel t#
Fshould become wbjM/o the Workers'Compensation Provisions oftha Labor TOTAL:
W Code,you=at forthwith comply with such provisions orthb permit shalt be
LU j, deemedrevoked. BUILDING FEE
dCONSTRUCTION LENDING AGENCY SEISMIC PEE a
7 hembyafRrmthot thele Is a construction lending agency for the perform- ELECTRIC FEE
M Z an.of the worktoiwhlch this permit bIssued(Sec.3097,Civ.CJ '
TOTAL: \
U O Lenders Name PLUMBING FEE.
14, H' Lenders Addmea ' ' QTY. +MECHANICAL'PERMIT', , 'nFEE a' MECHANICAL FEE
OW Irertt. that I have mad Iagretocmply withal]citlonand dcountetbauheabove inlorrtutlon ., x_
bcrrmct.Iugrerto<omply withal)dtyand county ordinances and state laws . PFRMITISSUANCE "LCIS' FEES PAID:
G' relatingto building construct.,and herebyauthmire representatives°tthes -
F Z city to enter upon the above-mentioned property for Inspection purposes, ALTER OR ADD TO MECH.
V —, (We)agree to save,Inde d'kuup harMess the Cky of Cupertino - Date,. Receipt# ,
agalns[Ila I@ba,jtdgmenb, expenses which may In any wayaccrue AIR HANDLING UNIT(T)10,000 CFM) SUBTOTAL:
against City In mnaryucn of negranting oft sperm, -
AIRHANDLINGIINTT(OVER10,=CFM) CONSTRUCTION TAX
ignew ppllmet retractor - Data I9(HAUS'THOOD(W/DUCT) CONSTRUCTION TAX PAID:
ARDOUS MATERIALS DISCLOSURE
W he applicant orfutum building occupant store or handle h.M., HEATING UNIT(TO 100,000 BTU)' Date ' RCcel [#
ma Ias defined by the Cuperti no Municipal Code,Chapter 9.12,and the - ��'[�
H I and Safety Cod a Section25572(a)7 HEATING UNIT(OVER 100,000 BTUs TOTAL: (,�l 7
Yes M No
Ill the applicant orfutum building occupant use equipment or device l VENTILATION FAN(SINGLE RESID) L.��'Sp .ISSUANCE DATE
kheMi havrdous air meta contaminants as defined by the Ray Area Air -
Quality Management Clarks? BOILER-COMP(3HP OR 100,000 BTU)
4+Ye, he 9 Nr
haveread Health
us Code, ercons25 enlsundernd 2S5 46.95 of BOILER-COMP(OVER IOO,00)BN) /�IN�
theCaliforniaHeath bSafety Code,Sections25505,vn.tand25531.I S RAM
understand that If not
the ing,doesocupa of of to requir haves tench;that itlsmy NEVJRI'SIDFNHAL MECH. SQ.FT.
responsibility tissua to act Corti occupant of requirements which must be met. [N � �^
' - prior to issuance of Certificate rl Occupancy. a7 � f\• 1`l,Y,J—).
Owner or aulhorimda ent
g. Date TOTAL: 'a ISSUED BY !-!��;
OFFICE COPY