22974 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT.PEN ONLY
Building Project Identification PFYMITNO.
Building Address:
ooze ��s NY o� 22974
APPLICATONSUBMIl IM,-ON1-$ CUBA-22uV11X-Z ane. CITY OF CUPERTINO-BUILDING DNI
A
qqb- oa ` t^`gyp
c°ntnnar'.Nama: um.N°: APPLICATION / PERMI 6 l
DI� HILq� IN`s loo1 S'2.( BUILDING-ELECTRICAL-PLUM M C CATEGORY CON'f�Lll)
ArcZ/Englacer. /� Llc.No: u r
tL U01-D5UJOZr" ( '` BUILDING PERMIT INFO
1 AS h U I L QTY ELECTRIC PERI1'II FEE
Address B I SIOljb . Sia PERMIT ISSUANCE ��^ 1V1 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Thereby affirtnthat tem licensed underprovlgone of Chapier9(commmc- APPLIANCFSRE9 E .JOB DESCRIPTION
Ingwlth Scctla,7o00)of Divis on3ofthe Butirssand ProfesslonsCode,and my
licenr isin fuR and effect. _ PANES
I Cla Lic.p Z�O
Date —1 Contract° 0 Lj r ( '• V�
ARCHITECPS DECLARATION (. 1
{Qq aOZC ]understand myplamshallbeused aspubllcrecords. V AM79 SQ.FT.FLOOR AREA $ISO.Fr.
E U Llceneed Protesslonsl 5ELECTRICAL LA(a Ot�
< OWNER-BUILDER DECLARATION
G
7 L.,
'-v Ihercbyal0rtnthatlant exemptfromthe Contractor's Llcenr Law for the SPECIAL CIRCUIT/MLSC
following reason.(Section 7031.5,Business and Professions Cade:Any city or
O 1:. T13.1P.METER OR POLE INST.
� rountywhkh rcqulreaa permittoconsttact,alter,lmprove,demoBeh,orrcpalr
anystructure prlortoits issuance,also mprirestheappRmnt forsuch permit to POWER DEVICES
L5 Ble a signed statement that he Is Ilcarawd pursuant to the provisions of the
Wb3u, Contractor.License Ls-IMapmr9(commencingwlN Section 70M)a(Divi- VALUATIOf{ala.�,
"b, SWI.(MING POOL ELECTRIC `[J
EQi the basis for
the
exemptions Code)orlglon of exempt therefrom and ��6_ I
<
the beats for the alleged exemption. Any violation of Seniors normo by any OUTLETSSWITCIIESFIXTURES
applicant fora permit subjects the applicant to a dull penalty of sat more[tars
five hundred dollars($500). 1 NEWRESIDENIALELECTR_SQ.FT. S'T'ORIES TYPE CONSTRUCTION
❑1,as owner of the property,or my employees with wages as their sale
C 7.a compensation,wRldotheworkandthestmMmisno Intended or offered for
$ Ct sale(Sec.7064.Buskiessand Professions Code:The Contractor's License Law
�Q does not apply to an owner of property who build&or Improves thereon,and OCC GROUP RES.UNITS
whodoessuchwarkhinselorthrough hlsown employees,provided that such
Improvements are nveot intended proffered forsalo.If,howeverthebuildingor
Improment le sold within oneyearofcompletion,the owner-builder will have
the burden of proving that he didnot build or Improve for Purpose o(saleJ. QTY, PLUMBING PERMIT FEE
0{as owner of the m FLOOD TDNE APN
property,am exclusively Business
and Ing with ns Codd PERMITISSUANCE
Th Contractor's
to consUuct thew doe(Sec.or apply
Buttner and Professions Code:
The Coor impr. s thereon,
Taw docs sat apply tct an owner of property who AL,rEg DRAW&VENT WATER(EA)
builds t improves thereon, and who contracts once. int such wSo)ecb with a
CTTIoner.a.formed nderpursuant Seto the Contnctor'a Llcenr Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
1_J I am exempt under Sec. B k P C for this rcaaon01]Tqinp FEES
Owner --in DRAINS-FLOOR,ROOF,AREA,COND. SANITARY V N
RECEIPT M
WORKMAN COMPENSATION DECLARATION FIXTURES.PER TRAP SCHOOL TAX Y_ N
❑I hereby af/ixm that 1 have o rrtiBanc of consentammifi to o y-inrre,ora RECEIPT a
certltlLab ofWorkexe Campensatlonlnsurance oracerti(Ied copythereof(Sec. GAS EA.SYSTEM-]INC OUTLETS PARK FEE Y N
Polis lab CJ
I'ollry M RECDING DI M
CAS G.SYSTEM-OVER 4(FA)
Com any - BUILDING DIVISION FEES
rtllled copy b hereby tum
ertl(Ied copy le(Tied with the
city ty Inspersion division. GREASE/WDUSTRL WASTE INTERCEPTOR PLANCHECKFEE 6
C
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID��� O
COMPENSATION INSURANCE SEWER-SANITARY STORM EA.2(NQT. Date Rewi [M
(TRlsrctlon need nbe completed the Permitione hundred dollars
($100)or lmvJ WATERITEATEt W/VENT/ELMIR ENE F Y 1 .
I comly that N the performance of thework forwhich this permit Is Issued, `
I shall not employ any person In any manner so as to become subject to the
O WATPR SYSTEM/TREATING �•
Workers'Compensation laws of California. Date PAID t0
Z Applicant NEW RESIDENTIAL PCMB. SQdrT. Dale RC(CI [#
Z NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should become subject to the Workers'Comperuation provlalms o/the Labor
CCN Code,you=at forthwith comply with such provisions orthb permitehall be
> deemed revoked. BUILDING FEt
W c CONSTRUCTION LENDING AGENCY SEISMIC FEE
IherebyafOrm that them l a mnstmctlon lendingagenry for the perform ELL•CTRIC FEE"
� Z anceofthe workfor which this permit V ipsued(Sec.309],Civ.C.) TOTAL:
UO Lender's Name PLUMBING FEE
LL F Landar'sAddress QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO 1certilythat l havemad this application and gate that theaboveinformatlon
111 bcorren.I agree to comply with all city and county ordl^a^msand gate laws PERMIT ISSUANCE FEES PAI D:
} G mlating to building mrutrunion,and hereby authorize mprerntathus otthis
H N city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH.
Z (We)agree to vc,Indemnify an d keep harmless the City of Cupertino Date Receipt#
V ago Wtllagreero, dgments,cogs end expensnegs which may In anywayacaue AIR HANDLING UNIT GO 10,000 CFM) SUBTOTAL'
against aid comaquenceof h gn; ntl of this permit.
AAAJJf//-.`Pn/p`-- //-I3-o I AIR HANDLING UNIT rovER 10,000 CPM) CONSTRUCTION TAX
Sigmture pll nt/Cont a Date 1 EXHAUSTHOOD(W/DICT) CONSTRUCTION TAX PAID:
AZAR) USMATERIALS DISCLOSURE
Will the applicant or fut rebuilding occupant store or handle hazardous HEATING UMT(TO]O(LOOOBIU) Date ReceiptN
materialas defined by the upertino Municipal Code,Chapter 9.11,and the - -
IiealthandSa(etyCode nton 25532(a)1 HEATING UNIT(OVER 100,000 BTU) TOTAL
❑Yes No
Will the applicant orfuturc building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air' p� pp {
Quality Management District? BOILER-COMP OFT'OR 100,00 BTU) IP T{ / V
.�i 4 Yrs I-No
,have read theth SafesCode,Le reons 2555,2553 and 2S534.r Chapter
of BOILER-COMP(OV(7t 100,000 BTU) AIII On
theerstand is Health do Safety COBe,Sedlmortl IL5,25.terta ,thatI1 L 1�1
undersmndytonolithe fy the occupant
of ng the requirments hick must
tb iso[ NEW RPSIDENTIAL MECIi. SQ.IT.
responsibility to notify the°entrant of the requircmenU which must be cors
prior to Issue nm of a Certificate of Ocm panty. Co
L
Owner or authortmd agent Date
TOTAL: 755I]EDB
OFFICE COPY