22682 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMITNO.
Building Address: O W 2� �� EW , . 22682
came: one: AAh
�, CITY OF CUPERTINO-BUILDING DIVISION
G°^t9i:' . Lic No: APPLICATION /PERMIT
Architect/Engineer.
CJCJ� BNLDINGELECliUCAL-PLUMBINGMECFUMCAL CATEGORY CONTROL M
� Llc.No
&Y ELECTRIC PERMIT FEE. ' BUILDING PERMIT INFO
Address: PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Iherebyalfirmt)ut l am licensed under provisions of Chapter9(commene. APPUANCES-RESIDENTLAL 1 ]Og DESCRB'TION
Ingwlth Section 7000)0!Dlvlslon3ofthe Buslmmand PmfessionsCode,and my
effect. E
.selainfull me faandef . PANS
Use mLk.
S w `
LicenClaLfec
Date �•�-
Contractor
ARCHITECT'S DECLARATION 201-1000AMPS
2. (understand myplatashallbeused aspublicrecords OVER1000AMPS SQ.Ff.FLOORAREA S/SQ.FT.
CO
U[0 Licensed Professional SIGNSELECTRICAL
6 Ei OWNER-BUILDER DECLARATION SPECULCRCUIT/MISC
7t' Iheiebyaf0rm that l am exemptfromthe Contractors License law for the
following reason.(Se 1Jm,7671,5,Business and Pmf.Ima Code:Any try or
O .METER OR POLE INS!.
K4countywhich requlresa permit tommtruct,alter,Improve,derrolbh,orrepair _
anystmeture priesto its issuance,alsomquirestheapplicantfor such permit to pOWERDEVICES
file a signed statement that he Is licensed pursuant to the provisions of the
Cmucactorb License Law(Chaphoi)(commencing with Setlon 7000).(Divi- SWIMMING IDOL ELECTRIC
sion3 ofthe Business and PMenionsCods)orthat he in exempt theretromand VALUATION
the basis for the alleged exemption. Any ,v(olatton of Section 703IS by any OUTLETSSWITCIiFSflXfURES
`
applicant fora permit subjects the applicautto a civil penalty a not..the.
five hundred dollars($SOW. NEW RESIDEN77AL ELECTR SQFT.
1,as owner of the property,or my employees with wages as their sole STORIES - TYPE CONSTRUCTION
7q compereatme,wlll dothe work,andthe structure isnot intended or offered for
P O sale(Sec 7014,Business and Profession,Code:The Contractors License law
3� does not apply to anowner a Property who builds or improves thereon,and .00C.CROUP RIS.UNI'T'S
M who does such work himselforthwgh his own employees,provided ttiatsuch
Improvements are not Intended oraffered forsale.If.however,thebuilding or TOTAL;
Improvement bsald within emyearofcompltioythe owner-builderwill have
he hated en of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT , FEE" FLOOD ZONE Aped
s net of the property,am exclusively contracting with licensed PERMIT ISSUANCE
c Vrs ro
at oto nvtruct the project(Sec.7044,Buelneas and Professions Code:
Contractor's Men.Iaw does not apply to an owner of property who ALTER-DRAIN VENT-WATER(EA)buthls or Improves thereon, and who contracts for such pkakcts with a
coptlactor(a)licensed pursuant to the Contractors License Law. BACK 710W PROTECT.DEVICE FEE SUMMARY
LII am exempt under Sec. B&P C for thin masonOUTSIDE FFF9
Owner Date DRAINS.FLOOR ROOF,AREA,OOND. SANITARY Y_ N
RECEIPT M
WORKMAN COMPENSATION DECLARATION
aa .Ell hereby.film"that I have a certiRaFIXNRES PER TRAP SCHOOL TAX Y— N—
te of consent to self.Insure,or RECEIPT M
certificate ofWorkers'Compereatlon Insurance or a certified copy thereof(Sec. GAS EA 5YS1'EM]INCA OUTLETS
3800,Lab C.) PARK FEE Y— N—
Pollry If GAS RECEIVE EA.SYSTTM-OVER4(EA) BUILDING DIVISION
ISION FEES[CRed
copy is hereby furnished. =WASMINTERCITT.IORUSTRL WASfE INTERCIB'TOR PLANCI-IECKFEE
❑Certified copybfiled withthecitylupe tiondivision.CERTIFICATE OF EXEMPTION FROM WORK ERB' PAID
not bee NSATIONINSURANCE ARY-STORM EA.20011'.• Date Recei t#
(Thissetl.n need net Mcamplcted Ifthepermit la!Dronehundred dollars(510 camifees) ER W/VENT/ELECTR ENERGY FEE Y NIcerti(y that in the perforrtunce ofthe work forwNch lie permit lsbwed, —
I shall not employ any person in any manner m as to become abject to the IM/TREATINGWorkems'Compensation Law.of California.DatePAIDO Z Applicant NTIAL PLMB. SQ.IT. Date Recel 1#
Z O NOTICE TO APPLICANT:If,a fter making thin Certificate of Exemption,you
should become sub),t to the Warkers'Compenul ion provisions of the Labor TOTAL:
cc N Code,yw must forthwith complywlth such provblomorthb permushallhe
> deerred revoked. BUILDING •E
LU O CONSTRUCTION LPNDING AGENCY SEISMIC FEE I
I hereby of lmn that there Is a construction lending agency for the perform- ELECTRIC FEE
0 once.(the work(or which thin permit is lawed(Sec.3097,Civ.C.) TOTAL:
V Lender's N. - - PLUMBING FEE
LL F Lender.Address QTY. MECHANICAL PERMIT FEE. MECHANICAL FEE
O W IceklfythatlhavereadthbappBationanddatethatlheabovelnformrtlon
1 brorn't.lagreetocomplywlthallttyaodcountyordi...csandstatelaws PERMITISSUANCE FEES PAID:
>. relating tobuilding comwtlon,and hereby authome,repreaentativesafthis
F Z city toenterupontheabove-mentmned Property for Inspection purposes, ALTERORADDTOMDCH.
(We) c to ave,indemnify a keep harmiess the City of Cupertino Dale Receipt#
L.1
agates la ities,judg -,costs xpensee whlchmayin any wayaccrue AIRFIANDLINGUNITERD10,000CFM) SUBTOTAL'
.gal s dCityio con a an ting of this permit.asses '
AIR HANDLING UNIT(OVER 10,E00CFM) CONSTRUCTION TAX
. goalof Applicant/C tram Data I' EYFUUST I IOOD(W/DUC'D CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WI the applicant or future building ocevpant.wes or handle haratdous HEATING UNIT(ED 100,000 BIIn
nDate Recei t#
utertsI as defined by the Cupertino Mu oidpaf Code,Chapter 9.12,and the -
I iealth and Safety Code,Seci1on 25532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes 'M No
Willtheappliant orfuturebuildlegoccepectuseequ!peen ordevices VENTILATION FAN 6INGLE RESID) ISSUANCE DATE
which emit hamrdomair contaminantsasdetlned bythe Bay Arca Air y� _�
Quality Mamugement District? BOILER-COMP OHII OR 100,0(0 BTU) f!�
4 Yes 4 No
Ph
read the hazar cus materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) 411�r 41991
the California Health&Safety Code,Sections 25505,25533 and 25534.I !car y
understand that lithe building does rat arrcntly have atenanL shat ltbmy NEW RESIDENTIAL MECH. SQ.FT.
nspomibility to notify the occupant of the requirements which must be react
prior to issuance t a Certificate o(Ompanry. ���'''\'''�,]]\���/�of���—j-Wig
40
Owner or authodaed agent Date ISSUEDBY:. �`�A/ TTS
OTAL:
OFFICE COPY