22704 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuitdinA Peeled Identification PERMIT NO,
Building Address: /�/"f n 0 A
d So . Sfellrn GG I 4
nCt9 GRIP. er .
A
/�rtlThy �XtPtPOrT CITY OF CUPERTINOBUILDING DIVISION
°nbrionr.Name: LIl.N°: APPLICATION I PERMIT l 3
U A 76�I9 BNLDINGELECTWCAL-PLUMBING-MECHANICAL CATEGORY CONTROL
Archltict/Engineer. Llc.N^:
din QTY ELECTRIC PERMITFEE "BUILDING PERMIT INFO
Add. TIME pilumb
PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I herebyaffirmX)thatl ivisi 3ofthesed derprovlaions of ndProCasiona 9de,and(cornmene.
my APPLIANCES-RESIDENTIAL JOB DESCRIPTION
inlicgwith aof nd
ofthe Businwand IPro(mslonsCode,and my s
Lines islnfull sC `d ic,# ,562299 PANELS
Lkenr Glom 4 �Ak f_
Date Contractor l uJ\
ARCHITECTS DECLARATION 271-1000 AMPS
pOse Z I understand my place shall be used u public records. OVER 1000 AMPS - SQ.FT.FLOOR AREA $/t.Fr.u O
k Licensed Professional SIGNS ELECTRICAL
OWNER-BUILDER DECLARATION SPECIAL CItCU1T/MIST
z �� herebya(!I mthatlam exemp fromthe Contra orb Llmnse Law fo the
following reason.(Section 7071,5,Business and Profession Code:Any city or
WF, F-, county which requbes a permit to construct,alter,Improve,demolish,or repair TEMP.METER OR POLE INST.
a any structure prior to its Lawsme,also requires the applicant for ouch permit to
ggg POWER DEV[CIiS
O
file a signed statement that he V r 9 fin ed pursuant it the tion 7 cam of the
Contractor's License law(Chapter 9(commenting with Section 7000)of Divi- VALUATION
H�0� slon3olthe Businwand ProfembnaCode)orthat hebeeempnherefromand 5WBdMING R70L ELECTRIC
the basis for the alleged exemption. Any violation of Section 7031.5 by any OUTLI TS-SWITCHESFIXTURFS
applicant fora permit subjects the applicant to a civil penalty of me..the. / o 0
five hundred dollars($500). 'NEW READEN77AL ELECTR FT.
I,as owner of the property,or my employees with wages as their sole `� STORIES TYPE CONSTRUCTION
7aco.;Z.alion,Mild.the work,and lhestructure E not intended or offered for
O<
rile(Sec.7014,Businessand Prof sigme,Code:The Contractors License Law
S� docs not apply to an owner of property who builds or improves thereon,and OCC.CROUP RFS.UMTS
p• who does such work himself orthrwgh heownemployees,provided thatsuch
Improvements arc not intended oro(fered forsale.IE hawevep nhebuilding or TOTAL:
Improvement Easold within one yearomompletion,the owner-builderwill have
the burden Of proving that he did not build or improve for purpose of sale.). QTy, PLUMBING PERMIT FEE FLOOD ZONE. APN
M I,as owner of the property,am exclusively contracting with Ikensed ppnM(T NUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License Law does nut apply to an owner of property who ALTER-DRAIN b VENT•WATER[FA)
Wilds or Improves thereon,and who contain for such p(ojeul with a
coed &or(c)Iirensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
ve
LJ 1 am exempt under Sec. B k P C for This man
Owner Data DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N_
RECEIPT'N
WORK MAN COMPENSATION DECLARATION FDnURESPERTRAP SCIiOOL TAX Y N_
�I hereby affirmorkem that I have o Insurcateance
of consent to selftrcopy
ora RECEIPT N
3800certiLab of Worken'Compemsatlon lmsuranca ora ceni(kd copy thereof(See GAS EA.SYSI'FM-1 INCA OUTLETS PARK FEE Y N
3X00,Isis C.)
Poucy# c5P16o546o GAS EA.SYSTEMOVER 4 ITEM RECEIPTM
Com ny BUILDING DIVISION FEES
Certified copy is hereby tarnished. GRRASE/INDUSTRL WASTE INTERCEPTOR PLANCI'IECKFEE
�Certifled copy b filed with the city beopeMlon division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA,2offET. Date RCCOI r#
(0)mI e.) need no[McomplMed If the perMl Vforonehundred dollars
($1I0)orlwd WATERHFATER W/VENT/ELECTR ENERGYFEE Y N
I ronotehalothe person
ofthe work far at;
btterpenult Is c issued,
I shall not employ any person in any manner m m to berome subject to the WATER SYSTEM/TREATING
Worlicre'Compemation Laws of California.Date PAID
Q Z ApplicanNOTICE
NEW RESIDENTIAL PLMB, Date Rem{ t#
Z 0 NOTTCETOAPPLjed to
a after making cam a Certificate Exemption,you SQ�FL
Code, become mistedto the Worknrt Compensation on or thioroomits Labor TOTAL:
W W Code,you must forthwith romply with such provislov or this permit shall b!
deemed revoked, BUILDING FEE
0. CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z Ihercbyafllren that them is a constroMlon lending agency forthe perlorrry TDTA ELECTRIC FEE
once o/the work(orwhich Itis perMtbdsued(Sec.3097,C1v.C.)
u O Lander'.Nam[ PLUMBING FEE . 019
LL F Lender.Adden. QTY. MECHANICAL'PERMIT FEE—r MECHANICAL FEE
O W Icertffylhutl have read this applicationani statethat theabove information
bcorted.I cgereto comply with all cityand countyordinames and pate laws PERMITISSUANCE FEESPAID:
} M relating tobulldiagcomtruMlon,and hereby authorize reprssentativesofthis
N city to enter upon the above-mentioned Property for inspection purposes. ALTER OR ADD TO MECH.
? (We)agree to save,indemnify and keep harmless the City of Cupertino, Date Reeel t#
V against liabilities,tadgmenls,costs and expenses which may In anywayaccme AIR HANDLING UNIT(TO 10,000CPh1) SUBTOTAL: 'UQ
ago Wtsald Clt from rare the granting of this pertnll. -
S< ��`k,, !,_,3_ I AIR HANDLING UNIT(OVER IO,000CR) CONSTRUCTION TAX
Sigrsture°f Applicant/Contractor Date RKIIAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will theappliam orfumre W hilog ocupantatoreor handle hazard... HEATING UNIT CED 100,00)BTfI) Date RCCe1Dt#
nuterial as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
IIn1thand Safely Cect
ade Sion25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL: _QQ
YesNO
WIIIIheappllcant or tare building occupant useequipreent ordevices VENHLATTONFAN(SINGLERESID) ISSUANCE DATE
which tend hazardous air contambsme m defined by the Bay Area Air
ality Management District] BOILER-CAMP UHPOR 100,"BTU)
° .Yes s RNo P.have read Healthe h
a sue miterLeis tioWreections 5SD5,2 Sand 5534.95°f gOR.ER-COMP(OV�2100,00087V) c •1'r''
the
erstannthat if th bSafety Code, otcomently hve a tend,thatiI p V
usponsind thrt lithe building occupant note requirments which
that it iset NEW RESIDENTIAL METH. SQ.Ff. M♦r 9
responsibility to n°tl(y the occupant of the r[qulrcmente which must be met
prior to issuance of a Certificate ofOccupancy. 44
Owner or authorized agent Date ISSUEDB �(
TOTAL:
OFFICE COPY