22359 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Proed Identification PEI"r NO.
Build ung Add�m,2��� 2,,VFVANN1 F' 22359
ners ante: one:
C}�algxs CITY OF CUPERTINO0.BUILDINGDIVISION
Can clor..Namin Lic.N. APPLICATION / PERMIT 1 I
BUILDINGELFCTMCAI.PLUMBINGMECIIANICALCATEGORY CONTRC
Rett/Engineer. Lie.No:
QTY. ELECTRICP MIT i /�FEEaErras BUILD INC PERMIT INFO
Add..: PE3tMITISSUAN 11Gni/ rel
LICENSED CONTRACTOR'S DECLARATION ILIJ
I hercbyefflim that l are licensed under provisions of Chapter9(comment. APPLIANC D )Oil DESCRIPTION
inensei infon force And
Buslnenand Pro(eselonsCode,And my
ingwitlslnfuBf(X0)cf effect. PA
License Clan Lk.N
Date Contractor
ARCHITECT'S DECLARATION
re
Z I understand my pint.shag be used u public records.NO 1 0 SQ.FT.FLOOR AREA y�$/SQ.FT.
OLirnnsed Profenlorul Sl
-c: OWNER-BUILDER DECLARATION SPEC LCIRCNT/M
Z3, Ihereleya(flrmtltatlamexempt(romthe Contractor'sLicense Lawlorthe
O F following reason.(Section 70315,Business and Professions Code:Any city or ` TEMP.M
counlywhlch requires&perrrdttocmutmdalteylmpmvedemolbh,orrepair
g anystm=mpAortoibhmance,aborequimtheappUmntforsuchpermitto POWER DEVICES
E5 file.signed statement that he is licensed pursuant to the provisions of the
GE1 3µII.� Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. SWIMMING POOL ELECTRIC a
E07 seen 3 ofthe Business and professions Code)orthat he b exempt therefrom and 4ALUATION
6.•�I7 the barb for the alleged exemption. Any applicantviolationtcivil
of netters sea
re Any OU7LETSSWITCI-Q5F1%7l1RFS I j0
thebaic for apermit lleged ..ethe ption. nyoa dull f Sectilty on
nm more than s
eve hundred darters he pr). NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
�n
1,as owner of the property,or my employees with wages as their sole ,
compnnsation,wllldothe work and theewcture
Lance bntended or oflered for
O nee(Sec.7064,Business and Professions Code:The Contractors Llceme Law
r3'$ does not apply to An owner of property who Wilde or improves thereon,and OCC.CROUP TULS.UNITS
who doeseuchworkhlmseRorthrough hlsownemployees,provided that such
improvements are set intended oro(fercd forsale.If,however thebulldleg or T
improvement issold within one yearof completion,the owner-builderwill have
t en of proving that he did not build or improve fee purpose of Aide.). QTY. PLUMBING PERMIT FEE FLOOD ZONL+ APN
I,as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
c I. to construct the project(Sec 7014,Business and Pro(enions Code: re
The Contractor's License Law does not apply to an owner of property who ALTER-DRAIN&VENTWATER(EA)
bunds or Improves thereon,and who contracts for such p(ojects with a - t^
cgy((actor(d licensed Pursuant to the Contneors License Law. BACK FLOW PROTECT.DEVICE 1— I
FEE SUMMARY
L I am exempt under Sea B A P C for this mason
OUTSI DE FEES
DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y N
Owner Date RECEIPT N
WORKMAN COMPENSATION DECLARATION TURES PER TRAP .►� SCI100L TAX Y N
]I hereby affirm that I have a certificate of consent to self-Insure,or a RECENT N
certificate of Workers'CompmnaRon Insurance oraarll(ied copy therso!(Sec.
3800,1.bC.) S GAEA.SYSTEM-1 INC.40UTIEf
. S /' PARK EEE Y N
Policy N - – RECEIPT N
Com any CAS EA,SYSTEM-OVER4(EA) BUI LDINC DMS I ON FE ES
Certl/led copy b hercbyth the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCFFECK FEE
( rtlOedcopy lshemwithrishey Inspection division. - .
CERTIFICATE OF EKEM"ION FROM WORK EBS' CREASETRAP PAID*7+q1 C4
S0
COMPENSATION INSURANCEgEWER-SANTI.ARY-STORM EA HpFf Date Remi t# O
(Thls.ccf..need not be completed lithe permit In for ane hundred dollars
($100)or len.) WATER HEATER W/VENT/ELECTR ENERGY FEC Y N
I mmi(ythat in the performance of thewerk k rwhlch this permit is issued,
I shall nm employ any person In any manner so As to become abject to the WATER SYSTEM/TRTATING
Workers'Compensation law.of California.Date PAID
O Z Applicant NEW RF9DFMIAL PLMB._SQFT. Date RCCeI t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Works.'Corepevat ton provisions of the Labor TOTAL:
N Code,you most forthwith comply with such provisions or this permit shall be O I
W > deemed revoked. '
a CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembyatfirm that there Is a commicion lending agency for the perform ELECTRIC FEE
D Z once W the work!or which this permit b Issued(Sec,309],CIV.C.) _
(.) 0 Lurder.Name - PLUMBING FEE _
LL Lender.Address QTY. MECHANICAL PERMIT FEE rtMECF-IANICAL FEE
OW lwftifylhatlhavemadthbappBcationand matethat theabove Information
1 Iscoect.t agree to comply with all city and county ordinances state laws PERMIT ISSUANCE ' �� FEES PAID-
>.
relating to building construction,and hereby authorize representatives ofthis -
Z city t4.gr .
s above-mention property for WpMion purposes. ALTER OR ADD TO MECH. a�
V _ (wve,mai n keep harmless the City of Cupertino Date Reecipt#
agaW ,coatsan sea which may In anyw a e AIR HANDLING UNIT(TO le"CPM) SUBTOTAL'
agsWon once of a grant g of this permitAIR HANDLING IINTP(OVER l0,000CFM) CONSTRUCTION TAX
S' cant/Co or ae EXIiAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HA2ARO BMA ALS UISCLOSUR
Will the applicant or mlare build pant store or handle hazardous 11RATING UNIT(TO 100,000 BTIp Date Recei t#
material as tle(Ined by the Cupertln uneclpai Code Chapter 9.17,and the
Fiealih and Safety Code Sectlen 755 (a)7 HEATING UNIT(OVER 100,000 BTUI TO
F-1Yes No
Will the applicant or future building occupant use equipment or devices ' VENTILATION PAN(SINGLE RFSID) Q.% ISSUANCE DATE
which emit hazardou.air contaMnantsa.defined by the Bay Area Air L Z•nn�� /�
Quality Management District? BOILFR-CAMP DHP OR 100,0W BTU) A A 'O
Yes n No ^1
haveread the hav7om mal cdc Serequlrementsuoder
.rd25534. 1 of BOdER-COMP(OVI➢2100,000 BTU) L�A�
theCaliforniat Health&Safety Code,Sect1orontly have
a tend,that I O
understand that lthebulldeg does not emcf lyhave alhich tenant, b[its my NEW RESIDENTIAL hfECH. SQ.FT. n' 17 /9g, n
ra-1 to ko.tyto of A Certificco ate
of of the mqulrcmentawhich must be met /// ' a7
prior to ivuance oft Certl(late ofOnvpancy.
Owner or authorized agent Data ISSUEDB Ur`Kl
TOTAL:
OFFICE COPY .