22288 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project lotrllfkation PFR.MITNO.
Building (/`Ig w dew: _ 22288
CITYOFCUPERTIN0.BUILDING DIVISION
-� G R7,?
' APPLICATION / PERMIT
"� BUILDING-ELECTRICALPLUMBING-MFLHANN:AI. CA]EGORY CONTROL/
Iteet/Engineer. It,No:
QTY ELECTRIC PERMIT FEE - BUILDING PERMIT INFO
Address PERhDTISSUANCE ❑ ❑. El
CONTRACTOR'S DECLARATION
Ihereby affirmthat l am lleeneei urdn prwlnions of Chapter 9(commemc APPLIANCESLtF3DENITIAL - JOB DESC N
ingwith5 r700D)of Dt"M.3ofthe B,od W00,
,and my
lloensebinfu e(bct. PANELS
Lfoen laaeaC [.-/V L{e/ (i�le
Date /ri/�///_Contr,UorUP TO 2DOAMPS
ARCHITECT'S DECLA 701.1(00AMPS
µQSOZ I understand my plaru shall be used as public records OVERI(OOAMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
E�� Llanaed Prof®ion it SIGNS ELECTRICAL MA LED I N
OWNER-BUILDER DECLARATION SPEC IALC)RCUDTMISC
m
t.., (hereby arfirrnthatI aexempt from the Contractors License Law for the / C
9 p6 (ollawing rtuon.(SMIm 1N15,BusNea and Pmfeselons Code:My dty orC
F52CQ countywhichrequbn,pert towrod,iltn,impmve,demolbh.orrepair TEMP'MHTR IOR POLE INST.
Sany structure prior to its lswanee,also requbesthe appgnnt formch permit to ILOWETt DEVICES
JMtE
6 O file a signed statement that he is liernsed pursuant to the Im wbioa of the
�sLL� Contract.,',Be.I..(Chapter 9(mmntetctffwith Section 9000)of Divi- gWEdMNG7170�EECTRC VALUA ON
05 slon3o(the BushwandProfesebro Code)orthat hebhe
exempttrefromand
Sit_ the b bufor the alleged exempties, Any violation of Section 90315 by any
ap 0> ,pph.t fora pemdt subjectathe applicant to,cid]pealtydnot morethan OVIT.EISSWITCHLRFTXTURES
C. 2 Bv!hundM dollars WM. NEW RESIDENTIAL ELECTR
�'�n u I,a owner of the property,or my employee with wages a their sok �'�' STORIES FS TYPE CONSIRUCITON
compcaadm,wtildo thework,and thertrucW re b not intended or offered for
Osale(Sec9064,Be.hes and Plefemba Code:The Codradora Lice.Law
$� don nol.pply town owner of property who builds or improves thereon,and OCG GROUP RES.UNITS
whodonwdworkhimselfaffi ugh Msownemployaa,provmedthatwch
ImprovemeMa are not Intended oroffemdl foresle.If,however,the bulkiing or TOTAL.
4nprovemeot b"within ore year ofcompletlon,the owner-budderwl8 have
t en of pring that dnot build or Improfee purpose orae.). QTY. PLUMBING PERMIT FEE
�N1,a owner wdidve of the property,am exelustwely contracting with Massed FLOOD ZONE APN
mntracror m corotact the pro}et(See 9014,BuninmaM Prof®brat Code. PERMIT ISSUANCE
The Curdnctors Llenox Law dm not apply to an owner d property who
bu0ds or Improve thereon,and who codntls fa such peo)ees with a ALTER-DRAIN&VENT-WATER(EA)
91111" er(s)Roeaed punramt to the Contractors Liox.Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
U I am exempt ueder Sec B&P C for this renin
Owner Date
DRAINS-FLOOR,ROOF,AREA,GOND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION BBC=1
❑l hereby affirmthW have a evrHBoconsent oa
te of nnt to self-Ine, a Fl%TVRFS'PER TRV' SCHOOL TAX Y N
ceNfcaetrtetonfed Wmpybhereey EurTcer.tlfkdcopythereof(Sec. RECEIPTS
yG) GAS EA.SYSTEM. WG40JILEPARK FEE
Pe2kf / RECEIPT
(Leray / � 1JGAcrEA.SYSTF]d-0VIER4(EA) BUILDING DIV
ISION FES
ertNed copyb(Iled with the CcylropMbn dlvlsim. GRF 15E/wIx/srt(L WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF IXEMPI'ION FROM WORKERS GREASE 7Rld' PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 330FT. afcti IM
(rhissectbnn dnothecompI&t ffthepermitb(momhundreddollars DC Re
(5100)or rt WATER HEATER W/VENT/ELECTR ENERGYFEE Y N
I tttffyphtheperformancethewmk%orwMch Wspemdtb bored,
I shall nurae empty any person h anrt y manner at e to become wb}M to the WATER SYSTEM/'TREATING
Waked Compensation La.d Gllrasb.Date PAID
NEW RESDENTIAL PLMB. SQFr.
Applicant
Z Q NOTICE 7D AI'PbjGtote after mallomperCflon provisions
r vis Exemption, Dote TA til
ahmldbecomewbh to the Worker'Compeaatlon orthl peo(the Labor TOTAL:
~ N Cadeymmdre eri. Nh comp)y with orcin provbbv or thio permit shill be BU
� ] Tamed newked.
W a CONSTRUMON LENDING AGENCY SEISMIC FEE
ILDING EE
tl IherebyafBrtn thatthereisa mrocmc mLnd g,gerwyfortheperform
TOTAL. ELECTRIC FEE
0 Z Lend o(the work(or which thio permR b lowed(Sec 309'/,
O Lender's Name PLUMBING FEE
u.
LL H Lender'sAaaw QTY. MECHANICAL PERMIT MECHANICAL FEE
O W ormet. thHlluve read this application and!•ace Wttheabovebdomution
11 bcoIngt build co cornplywoh all cltyaM county oNWnossadatabbws PERMIT ISSUANCE < FEES PAID:
} N relding to bullahg construction, au1bortre ncprexntatNe o(thb
F Z sty to enter upon the abew-me Property fa lropection purpose. ALTER OR ADD TO MECH.
Dove,Inde 'de e .armlee the Clry of Cupertino - Date Recel tit
V ago IU ,rydgmenb, apene wit khm,ylnanywa� AIRHANDLINCUNTT(rO10,000CFM) SUBTOTAL:
a rota hcvnsryu the granting dtMs IL MRHANDLINGUNIT(OVER10,(J00CPM) CONSTRUCIONTAX
91'ho.rp
rat/ ate IXHAUSr HOOD(W/DLCn CONSTRUCTION TAX PAID:
HAZARD USMATERIALS DISCLOSURE
lionturfutu ebu0dhg oavpnc atore nor handle hualloua HEATING UNIT(TO 1LD,000 I3iU) Date Revel t#
material as defined by the Cupertino MuMtlpal Code,Chapter 9.1Z and the
I kalth and Safety Code Section 255n(.)? HEATING UNIT(OVER 100,000 BTI]) TOTAL:
RYes No
Bl the appliaw or tune building occupant use equipment or devise VENDLATION FAN(SINGLE esLn) ISSUANCEDATE
which emit hx]ardous air contaminants as defined by the Bay Arca Air eL ►_a'us'�
QualXynMaagemcot District? BOILER-CAMP 0HP OR 1(10,000 BTU)
4YY r-1 No V`
hawe mdthe haaar�ou. rlal+requlrcmcnb undcrChLpter&95 of BODER{OMP(OVER 1W,000
the Health&Safety e,Sectba 75505,5533 and 25534.I J
that iftth buKEA
t mrrently have a tenant,that it b my NEW RESIDENTIAL MECH. SQ.FT.
ropomibi' lonotify tthe nequbementswh]ch const be 1s� .i(�j1plm{F(I'!
to rcc daCempanry. LFII? Y1 a`^'Le_"
i
aauthortr agcolLw Date
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OFFICE COPY