22472 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
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Building Protea Identification PFRMITNO.
Building Address:
'10SS fZOSQ g1 O-SU n� r 22472
re acus: ) J 1�� ,� �]/ A
LQ_, CY]aWQ'AiT .?,S7_7(Vo CITY OP CUPERTINO-BUILDING DIVISION p {
Lia"o: APPLICATION / PERMIT -1 _jq I.T
BUILDING-ELECTRICALPLUMBING-MECHANICAL CATEGORY CONTROL M
A.Mtect/Engineer, Lie.No:
QTY ELECTRIC PERMIT FEEBUILDING PERMIT INFO
Address: PERMATISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirm that l am licensed under provtsmacifChapter 9(on. APPLIANCESRESMDENTIALingwit )OB ESCRII'110N
11...h I.Fallforwa(DlWect. theBuelneaandPro(easloneCode,andmy two S�� k.t&'S
Items I.I.luB forward PANI75 (V1/ 11
License Claes Lle.p
Date Contactor
ARCHITECT'S DECLARATION 201-1000 AMPS
Ore Zp l understand my plan,shall be seed u public rerords OVER 1000 AMT'S SQ.FT.FLOOR AREA $/SQ.FT.
Ll...it Professional SIGNS ELECTRICAL
�<IE OWNER-BUILDER DECLARATION SPFGIALCRtCU1T/MLSC
t.., Ihereby affirm that am exempt from the Contractors License law for the
�mnLyngrearon.(Sealoe7 ttocomneaeand Pmpe ndeml:Anydty°r (EMP,METER OR POLE INST.
I C�^gip-{ cmntywhich requlmapermittocosstmd,alter,improve,demolish,orrepalr
q . anyst =mpdortoltsL ancgaMmrquirestheappBmntforsuchpermitto POWER DEVICES
E5�w file a signed statement that he is licensed pursuant to the provisions of the
3 c`1n Contad.e.LicereeJAW(Chapter 9(commencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
1z NN' �"
H OS sion3ofthe Buslneas and Professions Code)orthat bets eaempttherefromand VALUATION .
the basis for the alleged exemption. Any violation of Section 70115 by eny
«
applicant fora permit subje<lithe applicant to a d"I penalty of not room thin OUILE7SSVATCHESFl%TURES ,•S0�s �0
eve as owns of MOOLthe property,
NEW RESIDENTIAL ELECTR SQFI'. STOIt1ES TYPECONSTRUCTION
asownerll theproperty,orhe employees with Wages their sole
y4 c &e .70Kation,goal. the work,Pordec lm structure The C ansotro'ntended or kens Law
F d for
S sale(Sec.7064,to ainow and f property
Cade:The C impro is License Taw
�'j $ does whodotapplytornimselner orthmughhisonempoymprwvidedtoryand OCC.GROUP RFS.UNITS
WW whodoemntswork Mmaendedcrough hlsow ale.Ityms,er,thedihateuch
improvementsare not Intendedproffered for ale.thhowever rider ]ding or pl;
Improvembm tssoidwlihln oneyearofcomplaloRtbeowner-W Bderwlli have
thg-karden of proving that he did nabu0dorimprove(wpurposeofsale.). QTY. PLUMBING PERMI FEEPLOODZANE APN
U L as owner of the property,am exclusively mntrading with Iicemed PERMIT ISSUANCE
mntractors to construct the pmjed(Sen 7064 Business and Professions Code:
The Contactors License Law does not apply to an owner of property who ALTER-DRAIN&VFM-WATER(EA)
Wilds or Improves thereon, and who contacts for such p,jeda with a
cs)limned pursuant to the ContradoYs Limned Law. BACK FLOW PROTECT.DEVICE FEE CUT 1SUMMARY
Lf I am exempt under Sec. B k P C for this reason
DRAINS.MOO SOUP, SAMTARY Y N 91 OF •
VIN
Owner Date R AREA,COND. RECEIPT N
WORKMANIhave
COMPENSATION DECLARATION
❑I hereby affirm that have a mrtifinceP])(TURES.PER TRAP SCHOOLTAX Y N
te of consent to relf•Ineure,or RECEIPT M
mai(late o(Worken'Compevatlonlmuranre orarerti(led copy thenm((Sec. GAS EA.SYSTEM-1 INCA OUTLETS PARKFFE Y N
policy
Tab CJ
Com an GAS EA.SYSTEM-OVER DING 010
Y BUILDING OI VISION FEES
Certified copy b hercbyth the city GREASEANDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy V flied with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWEWSAMTARY-STORM EA.200RT. Date RCCeI tp
(Thtseedlon nmd rad becompleted If the permit V for one hundred dollars
(S1IID)itifytJ WATER HEATER W/VFNT/ELECTR ENERGY FEE Y N
I ll not that o any person
In any
mannerhe work an as to be.a subjrmitect
is lamed, —
1 Whale not employ any pesos In any manner an a m Wcome subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
Z Z Applicant NEW RESIDENTIAL PLMB._SQFf. Date Recti IN
Z 0 NOTICE TO APPLICANT.$after making this Certificate of Exempbn,you
should bemmn subject m the Workers'Compensation provisions of the Labor TOTAL:
CC N Code,you most forthwith comply with such provisions orthb permit shall be B ] G
deemed revoked. FEE
U.1
C CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there Is a construction lending agency for the perftn ryELECTRIC FEE
L) Z anca ofthe work for which this permit Is Issued(Sec.3097,Civ.C.) TOTAL. PLUMBING FEE
O lenders Name
ly L ndm
srsAddss QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Imrti(ythatl have readthi,applicationand stateihatthe above information
lammed.I agree to comply with all city and county ordinances and date Taws PERMIT ISSUANCE_ FEESPAID:
r M relatingtobulldtngmrstrudion,andhembyauthor mpmwntativesofthts
Z city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTOMECH. -
(We)agree to ave,Indemnl(y an d keep harmless the City of Cupertino Date Recti tit
V against liabilities,judgments,costs and expenses which may In anyway... AIR HANDLING UNIT(TO 10,000CFM) SUBTOTAL:
.gal a C 1 rorlatque cep the sating of it.
6�` Z AIR HAND LING UNITWOVER 10,000CrM) CONSTRUCTION TAX
Signature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTIONTAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WEltheappli it orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU)
matctl lasdefinedbythe Cupertino Municipal Code,Chapter9.IZ.ndthe Date Reeei t#
Health and Safety Colo Section 25532(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: l S
❑ Yes L_I No
Willtheapplicant orfuturebcildiagoccupantuseequlperent vilevires, VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which trot hazardous air mntamleants as defined by the Bay Area Air
Iity Management D'utdct7 BOILER-COMP phE'DRI(p,000 BT1n
4WYes n No
vcread Healthhe
SafetTous y
Coedab rcons2505,25533 aChapter6.95 of BOILER-COMP(OVER 100,000 BTU)
the understand
California Health building Safety Code,Sedlom 25505,ve a t and 25536. I
understand that ifthe lifyth .oup.en note currently equir have Which at
It key NEW RESIDENTIAL METH. SQ.FT.
prior
responsibility itytheoate of ccupa equlremeniWwhich must be met
prior to lacunes of Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
TOTAL:
OFFICE COPY
ply
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