22812 J APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
/ a
Building Project Identification PERMIT NO.
Building Address:
2 2 812
�e,,`am: p p
V l k(p Ll'L CITY OF CUPERTINO-BUILDING DIVISION
Contractor'sName: Llc. o:
APPLICATION / PERMIT to
Architect/Engineer. Lic.N. BUILDING-ELECTRICALPLUMBINGMECHANICAL CATEGORY CONTROL N
QTY ELECTRICPERMIT .FEE BUILDING PERMIT INFO
Add..
I'QRhRTISSIJANCE ❑ ❑
LICENSED CONTRACTOR'S DECLARATION El
I herebybmthatlam licensed provisions ofChapter 9(commenc.
APPLIANCES-RESIDENTIAL
inhSacdonofDlvf .(the BusindusandPro(easlonaCode,and my JOB DESCRIPTION
Llreense1sInfull to.and effect.
- PANUS O _ f
Lirense Chu LILY \rJWCL�'7r`
Date Contractor
ARCHITECTS DECLARATION 201-I9DAMP5
NO Zp I understand my plans shall be,used as public records. OVER1000AMP5 IA
1SQ.FT.FLOOR AREA S/SQ.FT.
�(1 LI¢nsed Professional - SIGNSELECTRICAL e I /_e D ■
6 OWNER-BUILDER DECLARATION 1 's //
71.., Iherebyaf0rmtlut fame (romthe Contractor a Llrenu[a Io.the SPECIALCIRCUT/MISC .!
following reason.( di.791.5,Buslness and Professions Code:Any fly or
G
c ntywhichmquircsapermlttocomtmctaltegimpmve,demolleh,orrepalr TFMP'MCIERORPOLEINSf. �+Cot6\/' YT E
m v anystrocwreprior to ibbsuance,elw requlrntM1eappBant forsuch permit tat POWER DEVICES
E V /1� � T
file a signed statement that W Is hunsed pursuant to the provisions of the DA
ContractorLicense (commending with of Divi-
s Lil (Ch9 h S 70
m01n SWIMMING POOL ELECTRIC
stool ofthe Business and Professiora Cede)arthat he b exem thfromand
< the basis for the alleged exemption. Any violation of Sectionere
791.5 by any y' C
O OUTLETSSWITC[iFSE%TURFS
applicant for a permit subjects the applicant to a civil penalty of not more than -2 -•�
flv a red dollars(5500). V
Ch` NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n ere owner of the property,or my employee with wages as their sole
comp utlon,wdldotheworkandthestructume =Wendedoro(femd for
O rale .7044,Business and Profcmlons Code:The Contractors License law
$�! does not apply to an owner of property who builds or Improves thereon,andOCC.CRON' RES.UNITS
who does such work himself or through hlsown employees,provided that such
Improvements are not Intended motioned for sale.If,however,thebullding or TOTAL:
improvement bsold withinoneyearofcomplelloo,the owner-bullderwill have
t t"rden of proving that he did not build or Improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
u L as owner of the property,am exclusively contracting with licensed PpRMOTISSUANCE
contractors to construct the project(Sec.70K Business and Professions Code:
The Contractor's License Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improve thereon,and who contracts for such pRojects with a
cq,E(actor(s)licensed pursuant to the Contractors Llrenu Law. FEE SUMMARY
u I am exempt under Sem ; B k PC for this mason BACK FLOW PROTECT.DEVICE
OUTSIDE ITcu-
ROOF
FLOOR R ,AREA,COND. SANITARY Y N
. Owner Date RECEIPT Is
WORK MAN COMPENSATION DECLARATION PICTURES PER TRAP S HOOL TAX Y_ N
❑1 hereby affirm that 1 have a losu rate of comm to copy
therm,ora RECEIPT N
MOD,Late bC.) rken'Comperuatloniruuranre oracertified copy thereo((5ee GAS EA.SYSTEM-]INCA OUTLETS PARK FEE Y N
Polis Lab C.)
C[3 N RECEGAS EA.SYSTEM-OVER 4(EA) DING D1 N
C°n' any BUILDING DIVISION I'Ii ES
[Coddlentified copy b hembyth the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑CertlOed copy b filed with the city Inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.200FT. Date Recut tin
(fhbM
Ilon need na M complMed If tM permit b forom hundred dollars
(f19)o
Imrtlfy fy that tithe performance WATER HEATER W/VENT/ELECTR ENERGY FEE Yofthe work for Rials permit is Issued, N -
I shall not employ any Person in any manner w as to hectoring subject to the WATER SYSTEM/TREATING
Workera'Compensation Laws of California. Date PAID
O Z Applicant NEW RESIDENTIAL PLMB._SQFT. Date Recei t#
Z O NOTICE ca egA,je to
after
em'Co thissationicatoofprovis Exemptbryyou
F shouldbecameeurthwit the plywit'Comperovisinprovhiomoflhe Lab b. TOTAL:
V) Code,you must forthwith comply with such provisions orthb permit shall be
> deemed revoked. BU 'E
W CONSTRUCTION LENDING AGENCY SEISMIC FEE
a Ihereby.fflhat them is a construction lending agency(of the perform- ELECTRIC FEE
Z ance of the workfor which this permit is Issued(See 3097,CIv.C.) TOTAL:
V O Landers Name PLUMBING FEE
LL ~ Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW lreAifythatlhavereadthisappllatbnand statethatlheabovelnfornntlo,
1 bcorrect.I agree to complywith all cityand county oNbanos and state laws PERMTTLSSUANCE FEES PAID:
>. relating to building construction,and hereby authorize reprcuntaivesofthis
Zcitytoenterupon the above-mentlomd property for Inspection purposes, ALTER OR ADD TO MFOH. Date Recei f#
— (We)agree to mm an d keep harmless the City of Cupertino P
agalmtllab111tbs,Wd nts, A%:mI expenses whicheraylnanywayaccrue AIR HANDLING UMT(T010,90 CPM) SUBTOTAL-
agobstsaid ence of the granting of this permit
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gnaw Ap Ica /Co tractor EXHAUST HOOD IW/DLsi CONSTRUCTION TAX PAID:
R US MATERIALS DISCLOSURE
Willtheap cantor rebullding oavpant store or handle hazardous HEATING UNIT(T019,000 BTU) Date Revel R#
materhlaadeMe Cupertino Municipal Code,Chapter 9.1Z and the -
HealthandSufetyCod�+.-S�ection 25S32(a)? HEATING UNIT(OVER 100,09 BTR) TOTAL'
❑ Yes u No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contamimnta as defined by the Bay Area Air
Quality Management District? BOILER-COMP 0HPOR 100,09 BTU
Yes ❑n No PAID D
M1averad the nialinth&So ffotyus Code,ls Sod
ements 2555,2553 and apter 2S54.I of BOILER-COMP(OVI]RiW,000 BTU) l'1`A'
the Catand hat if the
building
Code, et currently
25505,ve at and25574.l
understand that notify
the occupant
net ce mquire encs tenant,that Rbmy NEW RISIDFNTIAL METH. SQ.1T. OCT
responsibility to issuance
not ifytheiate of oft he mqulrerrcmswhich must be cont
prior to Lasuance of Certificate of Occvpanry.
Owner or authorised agent -61Date
TOTAL: ISSUEDBYt
OFFICE COPY