22567 APP,LICANTTO FILL IN INFORMATION WITHIN RED LINES -, JIJSE BALL POINT PEN ONLY
L - Building Project'Identification - 1' PIRMITNO.
Building 22567Luv ._,
GGnel.pName: me. APPLICA LION SUBMI I I Al.
V�IV 11�I� Y►u{1 ��j-�j;,P�v CITYOFCUPERTINO-BUILDING DIVISION
ontractnr's Na i-AP L .N : APPLICATION /PERMIT
a l
t �`�' �s •l a •`"-"k� .BUR,DINGF].ECTRICAI.PLUMBIhG hfFLFIANICAL CATEGORY CONTROL M/
A Rett/Engir�m. - m [r .
aELECTRIC"PB
QTY ii lT+'.".1BU. . . . .ILDING PEIT INFO ' ,:j
. RM. ...
Address: - SI• Sz -
LICENSED CONTRACTOR'S DECLARATION
Ihereby edion700)6f amlkn3ofthunder sinvs dPmfehaptnr9de,and c APPLIANCESRFSIDENTIAL JOB DESCRIPTION -
IngwlthSe hill to.
td affeen3o(the BuelnesandPm(ndone Code,and my JOB
Cie hill force and affect. PANELS
License Cla® 'LLCM
Date Contractor '
ARCHITECTS DECLARATION 201-1000 AMPS
9Z .understand my place,shall he used as public mosrds OVER1000AM IT.ILOORARFA $/SQ.FT.
ppF!{� , t
Eod Licensed Professional _ SIGNSELECTRI - y
<�G DI OWNER-BUILDER DECLARATION SPFCIALCIRCIR
XF, 4 Iherebyaffirmlhat7amcxempl fmmthe Cantradm'e Llnnse7awfmthe
oo following (Section 70115,Business and Professions Code:Any city or
O Z H - TEMP.ME77iR OR
FmC coontywhichmqulresapemdttommtmd,altepimpmvgdemolbh,orrcpalr `
$Ymt55 any structum prior to its Issuance,also requires the a ppinnt for such permit m ppkyER DEVICES
L5 W,E 6 file a signed statement that he Is licensed pursuant to the provisions of the `
(Oj Ou, Contndor'e License Law(Chapter9(co.ocing with SceRm� 70M)of Dlvl- SWIMMING POOL ELECTRIC VAL ATION 0 sion3ofthe Businessand ProfessionsCode)orthat helsexnmptiberefromand
6 the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETSSWITCEIESHXT[IRFS
applicant fora permit subjects the applicant to a civil penalty of not more than
ppa five hundred dollars($500). NEWRESIDENTIALELECTR
❑Las owner of the property,or my employees with wages as their sole �'�' ST010 '1Y1'E CONSTItUC'110N
ronapensation,willdo the work and the stm=m b not intended or offered for
D
sale(Sec 7044,Business and Profenlons Code:TMCorrado!,Lleesne law - " ✓
3$ docs not apply to an owner of property who builds or improve thereon,and P OCC.GROUP RFS.UNITS
whodoesuchwork himself mthmugh hisownemployen,provided thatch -
Improvements am net intended oroffered forsale.If,however,tbebuilding or TOTAL:
Improvement issold withinoneyearofcompletkofthe ownerbuBderwlllhave .� r ,,_PLr -
the rdeoof proving that he did not Wild or Improve for purpose ofeala.E' QTYUIc4BING PERMITiP "' '� "'I'FEE+'L as owner of the property,am exclusively contractFLOOD ZONE APNing with licensed PERMIT ISSUANCE
rontractora to construct the project(Sec.7044,Business and Protesslore Code: '
The Contractor.License Law don cad apply to an owner of property who
builds or Improves thereon, and who contracts for such projects with a ALTER-DRAIN k VENT,WATER(IIA) -
co,,NN77ador(s)licensed pursuant to the Coetrador's License Law. ! "'IIj:9y`.',I'' FEE'SUMMARY ,I 'T7 J'
LII am exempt under Sec. B k P C for this reason BACK FLOW'PROTECT.DEVICE -
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
OUTSIDE FEES
Owner Date RECFIIII'M
I WORKMAN COMPENSATION DECLARATION F7%'TURE4]'ER TRAP SCHOOLTAX Y N
❑I hereby affirm that I have a certificate of consent to self-Insure,ror,a R— Na
mrtlfinteo(Workari Compematlonlnauranmoramrtifk mpythemot( .
3800,lab C.) CAS EA.SYSTEM-1 INCA OUTLETS. PARK FEE Y N
Collry N- GAS EA.SYSTEM-OVER 4(EA)' RFCEIT M'
' Cany BUILDING DI VISION FI:
Certified copy is hereby tume city CREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECIC FEE 4 �
�Certlled ropy Is filed with the city Inspection division.
' t CERTIFICATE OF EXLTIPFION FROM WORKERS' GREASETRAP PAID
'COMPENSATION INSURANCE
(rhlssedionneodnot be completed ifthepermit lsforons hundeaddollars SEWER-SANITARY-STORM EA.200FT. Date Revel tM
.r ($I0J)ca,less.) ENERGY PEE Y_
WATER HEATER W/VENT/ELECTR EN_ j.
Imrtify that In the pe mor unn of the work for which this permit is Issued,
1 shall not empl m rson in any manner eo u become subject to the WATER SYSTpv]/TREATING
wur'.tom laws of Glifomla.Date _ PAID
Z•Z Applicant NJ W RESIDENTIAL Pf.MB. SQ.FT.n Date Recei tic
N077CET NT' ,after making this Certificate of Exemption,you
at became su jeertI eWorkers'Compensation provisions of the Labor
N Code,you must forthwit comply with such provisions crthls permit shall be BU N f
W 7 deemed revoked.
CL CONSTRUCTION LENDING AGENCY - - SEISMIC FEE.
I hereby affirm that there is a construction lending agency for the perform ELECTRIC FEE
0 scam ofthe work for which this permit is ostied(Sce.3097,CIv.C.) TOTAL:
V Lender's Name
• . - - 1- PLUMBING FEE
IL F Lender'aAddas, QTY. ,,_f,i MECHANICAL,PERMIT ,+I;FEE!, MECHAMCALFEE
O W J.difythatlhavereadihbapplicatlonanddatethattheabove Information - -
umrrect.lagenctocomplywithalcityand o6mmyordleancesand elate laws PFRMITISSUANCE' FEES PAID:
} 0relalingtobulldinm
gronutdon
l ,sni hereby.uthodre
zcpresentativesottMs
FEZ roytoceteruponthe above-mentioned propertyfor WmFL
peonpurposes. ALTERORADDTOMH. -
— (We)agree to save,indemnify and keep harmless the City of Cupertino Date ReeejJ)[N
against Babllltim,judgments,rods and expenses which may In anywayaccrue AIR haNDLING UNIT CEO 10,000 CFM) SUBTOTAL: -3
.gal oWO in consaryenn o(ehe grantingo hiQBplt J. / -
/J / '/ /t(. AIR HANDLING UNI'I'(OVER 10,000 CPM) CONSTRUCTION TAX
I re of plicant/Contractor
Data EXHAUST HOOD(W/DUCA CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltb pplicant orfumm building occupant store or handle hazardous HEATING UNIT(TO 100,000 BM Date r Recei t# ,
materials defined by the Cupertino Municipal Code,Chapter 9.12,and the )
Ilealth'and Safety Code Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: ,3
❑ Yes- No -
Williheappllnntor rare building occupant use equipment or device VPNDLATION FAN(SINGLE RE-SID) ISSUANCE DATE
which emit hazardous air contaminant...defined by the Bay Area Air - ®®,,FTkk
c
Quality Management District? ,.- • BOILER-COMP EIHP OR 100,000 BrA
TU) IM
4�Ycs L❑No
have read the haz.rUusmated.La requlrementimcier Chapter 6.95 of 110EEILCOMP(OVER 103,000 BID)
the Calif.mia Health It Safety Code,Sodium 25505,755]3 and 25534.I p 17 ris�s�
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT
re ponaiblity to notify the occupant of the requlremants which most be met
prior to Issuance of Certificate of Occupancy. _ n�1ufR
Owner or authorized agent Date ISSUED BY:`VI {�uuVV'CC
TOTAL
OFFICE COPY