22711 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build in Address:
%5tZ)2- l�o�� 1�V EZ22711
C1�lta �{ 31K�Cl2 CITY OF CUPERTINO-BUILDING DIVISION
con o? / {{.I JJo APPLICATION / PERMIT
61 Zg BUILDING-M.ECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL#
A Itect/Engincer. LW.No:
:S0, y C r n
QIN ELECTRIC PERMIT FEE BUILDING PERMIT INFO .
Address �V �tL�—L��r I�t7C� CM'1J PERMIT ISSUANCE (•�Tf 1:1 .� ❑ • ,
LICENSED CONTRACTOR'S DECLARATION Y
I hereby affirm that l am licensed under provisions of Chapter 9(commen APPLIANCESRESIDENTAL JOB DESCRB'I'ION
Ingwith Sedion7000)ot Dlvision3ofthe Businemand PmfeasionsCod andmy
!lanae PANELS
License Cla .1 Llc.p l% �1
Date Contractor !` 'fh
ARCHITECTS DECLARATION / 701-10(0 AMPS
QZ Iunderstanl my plars.hullbe used as public records OVER10.#AMPS SQ.FT.FLOOR AREA $/v.Q.FT.
O
b Licensed Professional SIGNSELFLTRICAL -
6 OWNER-BUILDER DECLARATION
1n SPECIALCIRCUIT/MLSC
I hereb afflrmthat l am exemptfrom the Contractor'.License Law for the
�O followlnhich requirosion7031$ uslnes.and Pfteprove, Code:Anydtyor TEMP.MECPROR POLE INST.
r^�Z�
countywhich primba esa pertNtb alsore uirmtheapmvgt fors.h,orto
any swdurep t,trant.that
he is licensed rtrsuant to the for inionsofpermit e POWER DEVICES
File a signed statement that he ts Incensed pursuant to the provisions of the
�a Contractor's License Lan,(Chapter 9(rommendngwith Section 711110)ofDWI- SWIMKNG POOL ELECTRIC VALUATIO
O n.n3ottheBusineesand Professloro Code)orthet hats exem there(rumand �Ox
S^S the boot+for the alleged exemption. Any violation of Sediont 7MI.5 by any OUTLETS-SWITCHES-FIXTURES
URES
appBantforapermit.bjedstheapplic.ntt...ivilpendtydnMmorethan
five hundred dollars($500). NEWRFSIDENTIALELECTR SQ.FT. STORIES TYPECONSTRUCTION
7 6 ❑I,as owner of the property,or my employees with wages as their sole
compensation,wllidothework andthe structure is not Intended or offered for
q O sale(Be.7064,Business and Professions Code:The Contract.?.License Law
$ does not apply to an owner of property who builds or improves thereon,and
5^ who does such work himselforlhrough his own employees,provided that such OCC.GROUP RFS.UNITS
Improvements are not Intended moffered for sale.If,however,thebuilding or TOTAL:
Improvement issold within oneyearofcomplMWn iheowner-bulWerwill have ,
til,Jlumen of proving thathe did not bund or improve for purpose o(sale.). QTY. PLUMBING PERMIT FEE
"L as owner of the property,am exclusively contrauing with Reamed FLOOD ZONE MIN
PFRMIT155UANCE
contractors to comlruct the project(Sm 7044,Business and Professions Code:
The Contractor's License Law does net apply to an owner of property who
Wilds or improves thereon,and who contracts (or such #'legs with a ALTER-DRAIN&VENT-WATER(EA)
¢, a.r(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
<p
�I I am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N_-
• Owner 'Date RFLFJIPTp
RATION
WORKMAN COMPENSATION DECLA
01 hereby al(Irm that I have a certificate of consent to self-Weurc,oraTURFS'PER TRAP SCHOOLTAX Y N_
RECEIPT N
certiBateo(Workers'Com�p7ewtion lruu���Jr� pcertined copy tnemof(Sec. GAS EA.BYSfEM-I 1NC.J 0[fILEIs PARK I'FE Y N
3800,tats C.) �' /2G / 2 � I or 1 RECEIPT'#
Policy#_ y
❑PCertl GAS EA
EA.SYSTEM-OVER
Com any rtlfled copy it(fled with thea city
inspection divlslon. BUILDING DIVISION FEES
cpyit hereby tum --r GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-BANITARY-STORM EA.2WF7. Date Remipt#
(Thissectlon need net be completed If the permit h forom hundred dollars
($100)or less') WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I certi(ythat In the performance of the work forwhich this penult is issued,
I shall not employ any person In any runner se,as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation laws of California. Date PAID
0Z
Appllant NEW RESIDENTIAL PLMB, 5Q.Fr. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Compemat ion provisions,of the Labor TOTAL:
� ; Code,you=at forthwith comply with such provhlom orthts permit shall be BUILDING FEE V
ILI deemed revoked.
CONSTRUCTION LENDING AGENCY 'SEISMIC FEE L
CL !herebyafflrmthat there is a construction lending agency for the perform ELECTRIC FEE
M O ance of the work for which this permit is issued(Sec.3097,Civ.C.) TOTAL: -
Lander'.Name - - PLUMBING FEE
LL H Lender's Addre.s QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O 1certifythatl have read thisappllcationand nate thauheabove Information
IL n
Isc. ed.]agrceto eomplywlthall dtyand eountyominanoes and state laws PRRMITISSUANCE FEES PAID:
>. IA relating to building construction,and hereby authorize representative.of this
I— Z city to enter upon the abovnmcntloned property forlmpectlonpurp.ses, ALTERORADDTOMECH. Date Receipt#
(we)agree to save,indervnl(y an d keep harMcm the City of Cupertino
V against liabilities,jidgnxmts,con.and expenses which may in anywayaccme ATR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the granting of this permit.
AIR HANDWNG UNIT(OVER t0,0010CI•M) CONSTRUCTION TAX
Signature of AppBant/Contractor Data E7(HAUS'r HOOD(W/DUCT) CONSTRUCTION TAX PAID:
.HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 B'tU) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.IZ and the
Health and Safety Code Section 25532(a)7 m HEATING UNIT(OVER 10(,1000 BTU) TOTAL:
❑Ye. , N No -
Willtheappliantorfutum building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hannims air contaminants as dented by the Bay Area Air
Quality Management DlstrlM7 BOILFR-COMP OTB'OR 700,000 BTU)
4 You Na
haveread the hazy care materials requirement under Chapter 6.95 of BOILER-COMP(QVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25S33 and 75534.1 RNQ
understand that lithe building does not currently have a tenant that it 0 my NEWRFSIDENTIALMECH. SQ.FT
res blit Io notify the occupant of the requirements which must be met pea 'I qQO �a
ppfe cats IOatc of Occvpan � /� �Q�/ y71a 1- /r O 1si1171 /
ll//�� (/ / 7f� p
Owns r authorized agent Uate 1g9UEU
TOTAL:
OFFICE COPY