22778 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PE&flTNO.
BuOaing Address: 2 2 7 7 8 '
aoyy SAN FF,evq Do Ct C'uP6ATiN0� GA, 9So/y GG TVS
bunters ante: O One:
&VTOON CITY OF CUPERTINO-BUILDING DIVISION 1-
nntslS Z APPLICATION / PERMIT sL
7 7 BUILDING-ELECTWCAI PLUMBING-MECI LANICAL CATEGORY CO
A /Engince, 1 Lie.No:
I ';QiY - ELECTRICPERMIT ,.. FEE ,. BUILDING PERMIT INFO'
Add— LIDS P PFRMITISSUANCE
LICENSED CONTRACTOR'S DEC R ION Lf31 I/��
I hereby affirenthat l am licensed under pro isi Chapter9(commenc APPLIANCESRESID JOB DESCItExr10N
Iegwlth Sectlon700D)of DiWWm3 ofthe BusleessaedProfeaslons Code,and my `
time.is In mH force and affect. T.
P ^r
Llano tr
Date Contractor h•I'..a �
HITECI•S DECLARATION 00 AMPS T G'�Tl.
qq��++aO 000 I understand my plans shall be used as public records VER 1000 AMI SQ.IT.F7.O.�OF AREA S/F0.•FT.
p n
NO Licensed Professional SIGNS ELECTW 26 �7 �Za Jd
< -- l 237y DdL(a jb
�< OWNER-BUILDER DECLARATION SPECIALCIR IT/MLSC
Pis 1hercbyaffirrnthAIs.exempt from the Contractor'.Llcen. for the —
pp followingreason.(Semon 70313,Businessand Pmfeaabna Code:Any city or �.• e
TEMP.METER OR POLE INST. O
CE anysimhimpr orlmaismant aMrequimstheaprovntforsbh,orrettopair Ya�9 �/�( 7/, ?2_ 20. 6
$ any atruaure tatemente Issuance licensed pursuant to
pr vig..eof t e POWER DEVICES (
1 W file a signed statement that het handed pendant to the pro on 7000)of the
3a� Contractorsusinselaw(Chapten9(rommencingeWeM1 prtthemfm andivi- gWp,(hgNG A70L ELECTRIC VALUATION
O p� tion abfor the alleged
d ProfessionC Any
violation f exempt therefrom and �D
�5�pu Sr' the tzars for the alleged exemption. Any violation of Section 7011.5 by any OU7LE.fSuWLfCFIGSI7XTUIiFS p
fivehundred doermi($SMctathe appllcanttoa civil pemltyo(not more than J �]
I, m
fivehundred dollars(5500.
�n ❑I,as ownerofthe NEWRESIDENTIALELECTR SQ.FT. STORIES TYPE CONSTRUCTION
property,or my employees with wages act thele dole
P stion,wtlldothe work,andthe structure fif nest Intended or offered for
sale(See 7(144,Businessand Professions Code:The Contractors Llcen.Law -a—."'��"s i"�• L 1
tj r3$ does not apply to an owner of property who Wilda or improves thereoq and R l UMTS
whodoe.suchwarkhim.lforthrwgh hisownemployees,provided that such
Improvancra are not Intended oroffered forsals.If,however,thebullaing or T R
improvement issold within oneyearotcompletio,theowner-bu0derw111 have
theq�urden of Firming that he did not build or Improve for purprue of w4.). QTY. PLUMBING PERMIT Q pN
u L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec 7044,Business and Professions Code:
'- The Contractor's License Law don net apply to an owner of property who ALTER-DRAIN k VFNT-WATER(EA)
WOda or Improves thereon, and who comment fee for such p(ojewith a
anatlor(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.D[VICE' FEE SUMMARY
�-J I am exempt under Sec. B h P C for this regiona'IISI DE FEE S
Owner Date
DRAINS FLOOR ROOF,AREA,CONTI. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIPT M
❑I hereby affirm that I have a artiRate o!consent to.It-Insure,ora FIXTIIRES PER TRM SCHOOL TA% Y N_
artlflate of Wmken'C..Pc.tk n I.....ora certified copy thereof(Sec. RECEB'f N
3800,Lab C.) - GAS EA.SYS1E20.1 INCA OUTLETS PARK FEE Y_ N
Policy N R[:CEIPf q
GAS F.A.SYSTEM-OVER 4(RA) BUILDING DIVISION PEES
ray
ertNed copy's herebytthe cid. CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE f
Certified copy la(fled with the city Inspection divlelon. D
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWMRSANITARY-STORM FA 200F1. Date Rece) t#
('TMssection need not be complMed If the permit b for one hundred dollars
(51Icmlem.) WATER HEATER W/VENT/ELUCTR ENERGY FEE Y_ N_ 20 r�
lartily thato an performancenyofthe
nawork forwhich as to
permit leBeed, .C.1./
I shall not employ any person In any manner so ss to become subject to the WATER SYSTEM/TREATING
Workcra'Comon penaatllaws d(Cali(ornla.Data PAID
ZZ Applicant' NEW RESIDENTIAL PLMB. SQFT. Date Revel tH
O NODAPPLICANT.PLICANT:I/,after making this Certificate of Exemption,you
should become aub)ect b the Workers'Compensation provisions of the Labor TOTAL:
~ N Cod,you must forthwith comply with such provisions or this permit shall be .'
W ] deemed revoked. UIL 3
a G CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby affirmthat there is a construction landingagency torthe perform- EL' T' C •
D O and,ofthe workforwhichthb permit If issued(See.3097,Civ.C.)
(J Lender'.Name PL
ly H B FEE
Lenda'sAddress QTY. MECHANICAL PERMIT FEE 'ME MCAL FEE
U I cedlfythatl havereedthisappliwthmand statethatthe above Information
0 W Is correct.l agree to comply with all city and county ordinances and elate laws PERMITISSUANCE ^ FEES PAID:
->. (L relating to building corotruction,and hereby authorize representatives of this
N city to enter upon the abovcmenlioned property for inspection purposes. ALTER OR ADD TO MUCH. '
? (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date R eipt#
V against babWlies,Iidgments,comsand expensed whichmay in anyway. rue AIR HANDLING UNIT(TO 10,000 CFM) SUB OTAL•
Apia,LllId City In coneryu na of the gynting 01.permit AIR HANDLING UNIT(OVER]0,000CFM) CONSTRUCTION X
L
�>Iiliffc of Appumm/ContractorDat EXHAUST HOOD(W/DUCT) CONSTRUCTION XPAID:
HAZARDOUS MATERIALS DISCLOSU E
Wllltheappllrant'or future building occupant store or handle hazardous HEATING UNIT(M 100,000 BM Date R ei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the -
Sleet—
Health and Safely Code Section 75532(.)7 HEATING UNIT(OVER 100,000 BTI!) •I•
❑ Ye. No
Will the applicant or turn building occupant use equipment or devices VEMIIIATION 17AN(SINGLE MID) ISSUANCE TE
which omit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP(3M'OR 100,00 BTU)
F1 Yea g No pp
have read the hazy us materials requirements under Chapter 6.95 of BOILER-COhrP(OVER 100,(1(0 B7 U) P A
the California Health k Safety Code,Sections 25505,25533 and 25534.1
undenta rad that if the building does not currently have a tenant,that it la my NEWRESIDENTIALMECH. SQ.Fr. /I Ar 29 ^
resporelbility,to notltythe occupant of the requirements which moat he met �'I,tl �nA�
prior to Issuance of a Certificate of Occupancy. Cllr s7s7
- V ur r
Owner or authorized agent Data - I^ ISSUED$ f
T L
OFFICE COPY