22550 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
BuBdiag Address: f"I 17 O
r7 MIC/ G G
: TA
tSS PSTN a
Ow a araeCITY OF CUPERTINO-BUILDING DIVISION �j r
Cpay.dm'sNa / LIc.Na APPLICATION / PERMIT O o
IMF ^•/ GZ BUILDING-ELECTR[CA4PLUMBING-MECHANICAL CATECAAY CONTROL M
Archuet/EI n Llc.Na:
QTY ELECCRICPERMTP .FEE BUILDING PERMIT INFO
Address: I
PERMITISSUANCE ® ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
IWrebyaffirm n7000that lamlicensed m3ofheBusi sandpm Chapter9(rommme- APPLIANCES-RESIDENTIAL JOB DCSCRPHON
Ingwlth 1.fidj 7W0)or Diffect. fthe Bumneesand Pro(esslonsCade,and my
Branae lsln fuB force and drect, PANELS—UP TO 2DO ANTS DeD /�Q�
License ClassLont ((//
Dale Contratar
ARCHITECTS DECLARATION 201-1000 AMPS
ZO I understand my plans shall be,used as public records. OVERIOOOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
}e do j Licensed Phil essimutl SIGNS ELECTRICAL ..
GG6 OWNER-BUILDER DECLARATION
{n� SPECIAL CIItCIRT/MISE
7 p, Ihercby affimnehat lam exempHromthe Contractme's Littnse Law/ar the
foling reason.(Section 70715,Business and Procity or
Professions Code:Any ci
O '. lowTEMP.METER OR POLE INST.
�� countywhich requtmsa permdttocommct,alter,Improve,demolish,creepier
anystructure priorto its essuance,ahorequireathe applicant for such permit to )OWER DEVICES
(� file a signed sGuterent that he is licensed pursuant to the provisions of the
Contractor.License Law(Chapter 9(commencing with Section 7000)of DIv1- VA�Ay0: ./7
SWIMMING POOL ELECTRIC l6 1/
SOS elon3oftM1e Bualneesand ProfeniomCode)orthathelnexemm7Q3Ifby.y O.
the baals for the alleged exemption. Any t tolacivi a(na tion 70715 by any OIJILE•fSSl17.ICFIFSFl%7lJRFS
OS
applicant for a permit subjects the applicant toadvll,emery of not more than
$ five hundred dollars($500). NEW RESIDENTIAL ELECTRFT.
❑I,as owner of the pro",or my employees with wages as their sole STORIES TYPECONSTRUCTION
7a compensation,willdothe work,and the structure boot intended or offered for
O sale(Sec.7044,Business and Profesalom Code:The Contratoes License Law
F�$ does not apply to an owner of property who Wilds or improves thereat,and OCC.GROUP RES.UNITS
who doessuch work himself crthrough his own employees,provided that such
Improvements arc not Intended oroffered for sale.If,however,thebullding or TOTAL:
Improvement bmld within oneyearofcompldlomtheowner-W Bderwlll have
tflLiturcien of proving that he did not build or improve for purpose of sale.).City. PLUMBING PERMIT FEE FLOOD ZONE APN
U L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
to construct the project(Sec.7014,BusIness and Professions Code:
The Contractor's License law cion net apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves,thereon,and who contracts for such pcts
goJewith a
cgp�(aemr(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
[_J I am exempt under See. B&P C for this reason BACK FLOW PROTECT.DEVICE r'o lTqi no FEES
DRAINS FLOOR ROOP,AREA,COND. SANITARY Y N Owner Date RE"CEPf N
WORKMAN COMPENSATION DECLARATION FDnURF_S PER TRAP SCHOOL FAX Y_ N_
❑1 hereby affironorkers that I have o certificate c of consent to opyacti-insomheme or RECEIPT N
certificate o(Workera'Compamatlon Insurance ora ttrtl(led ropythereof(Se.
3800,Lab CJ GAS EA.SYSTEM-1 INCA OUTLETS PARK FGE Y N
Policy N RECEBT N
Co GAS F.A.SYSTa40VER 4(RA)
Jrm Cert _ BUILDING DIVISION FEES
'MLT- Cchilled copy b heed with furnished. GREASC/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
chilled copy b(Bed with the sty inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEINER-SANITARY-STORM EA 200FT Date Reoei t#
(This section need rout be completed If the permit b(crone hundred dollars
$t1n)orlet.) WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
I cent that N the person in any m work so a to b this become
c lamed,
I shall not employ any person In any manner m as to become subject to the WATER SYSTEM/TREATING
Workems'Compensatlon laws of California.Date PAID
ZZ Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Remi t#
O NOTICETO APPLICANT;If,after making this Conflate of Exemption,you
should become subject to the Workers'Compensation provisions or the Labor TOTAL:
S CO Code,you must forthwith comply with such provislom orthia permit shall be BUILDING .�•.
j deemed revoked. -
CL G CONSTRUCTION LENDING AGENCY SEISMIC FEE t
CL Ihercby a(Rmn that there b a romtmedon lending agency for the perform- ELECTRIC FEE
7 Z ance ofthe work forwhlchthla permit b Issued(Sec.3097,CIv.C.) TOTAL:
O O Looder.Name PLUMBING FEE
LLI- Lender.Addmsa QTY. MECHANICAL PERMIT '`FEE MECHANICAL FEE
O W Icedlfythatl havereadthhappliatie...dmatethAtheaboveinformation
Incorrect.l agree to comply with all city and county omllnantts and mate laws PERMIT ISSUANCE FEES PAID:
>. 1 relatingmb teuetion,and herebyauthorizerepresentativesefthb
N city to int upon thea ve mebtioed property for Inspection purpose. ALTER OR ADD TO MECH.
Z (We) gree to ,Indemnify an d keep harmim the City of Cupertino Date, Reeei t#
V agals bbllitles ' gments od expenses which may In anyway acwe AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
:gal sat in n enceof hegmn go(thl.permit. 7h
AIR HANDLING UNIT(OVER I0,0D0CFM) CONSTRUCTION TAX
SI reef Appllant/Contractor Da EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS ATERIALSDISCLOS E
Will theapplitent or future buildingoccupantstone or handle hazardous HEATING UNIT(TO 100,00 BTU) Date ReCei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the S-0Health and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTII)
❑Yes L_I Nc TOTAL:
72-'Will the a ppleant or future Wilding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSU�"TE
which emit hamodous air conlamimnb as deRed by the Bay Area Air r��
Quality Management District? BOILER-COMP OTE'OR 100,000 BTU)
Yes n❑No
havercadthehazardo..materials requirements under Chapter 6.95 of BOILER C'OMP(OVFR 100,000 BTU) �� ��TT�Rqt
the Califomla Health&Safety Code,Sedions 25505,25533 and 255M. 1 `Ti
understand that if the building don not currently have a tenant,that It is my NEW RESIDENTIAL MECH. S'Q.FT. `
responsibility to notify the occupant of the requirements which=at be ret `•`sr
prior to Issuance of a Certificate of Occupancy,
eft,at
Diner or authorized agent Date ISSUED BY: %j• V�1..
TOTAL: -
OFFICE COPY