22481 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALLPOINT PEN ONLY
Building Project Identification PERMIT NO,
Building Address:
03 43nc22481
oarsarra: one
W.W.
A
P tJCS�A,pa CITY OF CUPERTINO-BUILDING DIVISION Z�
. Corlmetor',Name: Lic,Ne APPLICATION / PERMIT
BUILDING-ELFJCTRICALPLUMBINC-MECHANICAL CATEGORY COOfr.X
Arc Itect/En��nee ( Lic.No: _ Lp
0. (�� QIY- -ELECTRICPERMIT FEEEcI BUILDING PERMIT INFO
Address:02 No� SaeayiiA WIrVZ W
P47thBTIS5UANCE ❑
L10EN5 ED CONTRACTOR'S DECLARATION
Ihereby di..7000that lamgolicensed 3oftheunder
usimmslonso(ChapteCode,amenc- AI'PLIANCESRF.SIDENTIAL )OB DISCKIPHON
ingwith In full
to.and vfect. otlhe0ualnemand profnslonsCode,and my �--'
lass.lsl.. !orae and effect. PANELS p� �yyL�
D.tc_ Clam Lk.X �—
Date Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
��qqvv re Zp I understand my planasluB themed as pubberecords. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k Licensed Professional - SIGNS ELECTRICAL
<6 OWNER-BUILDER DECLARATION
I hereby t ]a affirm that I am the CLlLfSPECIALCIRCUIT/MISC
Z F•Y1 y exempt from e ontractor's mnm Law or the
q❑ following reason.(Section 70115,Business and Profession.Code:Any city or
Fg muntywhichrequlresapermlttomrutmct,alter,4npmve,demlbh,orrepalr TEMP.METER OAI'OLE INST.
'� anystructure prior tottaissuance,also requtreatheappliesm forsuch permit to
Ofile a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
a Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi. VALUATION
sion3ofthe Business and Pro(emlorsCodc)ortha helseumpttherelromand SWIMMING POOL fl.EGTAIG
the basis for the alleged exemption. Any vlolatlon of Section 70715 by any
HPappllcant fora permit subject.the applicant to a civil penaltyofoatmorethan OUTLETSSWITCFiESFIXTUAESf � O(s�Ot00five hundred delta.($500).
n I,as owner of the property,or my employees with wages as their sole NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPE CONSTRUCTION
emopensatton,willelothe work,and the structure Is not intended or offered forsiO .1.(Sac.7044,Bunessand Profemiom Code:The Contractor's License Lawj$$ docs notapply toanownerof propertywha Wilds or lmpowasthereon,and OCC.GROUP RFS.UNfPtl
whodoes..chworkhlmselforth=ghhisownemployeespravidedthatweh
Improvements are not Intended orofferad forsale.If,however,thebuilding or TOTAL:
improvement b sold within oneyearofcompletion,the owner-bullderwill have
the burden of Foreleg that he did notbulld orimprove for purpouofmis,). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
171 L as owner of the property,am exclusively contracting with limment PERMIT ISSUANCE 1 -
contractors to construct the project(Sec.7044,Business and Professions Code-
The
The Contractor's Llmme Law don not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon, and who contracts for such projects with a
��Wl+ctor(s)Beamed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
OUTSIDE IT
Owner Data
DRAINS FLOOR ROOF,AREA,COND, SANITARY Y N_
WORkAtAN COMPENSATION DECLARATION RECEIrTX
FO(.IVRES PER TRAP cc SCIi001,FAX Y N
❑I hereby artless that I have o cessuram of consent to copy
of(S a l RECEIPT M
3800,uniLab at Workers'Compenaatlonlnauranre oracerti(Ied copy thereof(Sec. GAS EA.SYSTEM-1 INCA OUTLETS �X
3800,Isis CO '<s® PARK FQI Y_ N—
Policy X
aRECEIPT
C❑CnGAS EA.SYSTEM-OVER 4(EA) BUILDING DI VX
ISION FEES
edified
copy Ls hereby te
❑Certified copy V(lied withh the city
inspection division. GREASE/INDUSTRL WASTE INTERCEPTOR ANC ECKFEE
ty
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TAM PAID 2Zlf If G2S, 4e
URA
I
COMPENSATIONINSURANCE
Rhissection nand not be completedSURApermit V(Drone hundred dollars SEWER-SANITARYSPORM EA 200FT Date Receipt WztO
($10(fimless.) WATERHEATERW/VENT/ELECTR ENERGY FEE Y N
I rertlfy that In the performance of the work for which this permit is issued, —
1 shall not employ an/person In any manner so as to became wb)ect to the WATER SYSTEM/TREATING
Warkars'Campen.atkm Lawsof California. Date AID
0 Z Applicant If, NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t# t
Z O NOTICEco APPLIC.sub), tote after makinrs'Co pethiationirateof Evemptioryyou l
anode, becomesubjecttothe Workers'Compensation;orthiovofthe Lab or TOTAL'
� W Coddeemed a okeHortnwith comply with each provbiav orchis permit shall be U L
deemed revoked.
aG CONSTRUCTION LENDING AGENCY SEISMIC FEE a
I hereby affirmthzt there Is a construction lending agency for the perform- ELECTRIC FEE
Z ance ofthe work for which this permit blewed(Sec.W97,CIv.C.) TOTAL: 4
V O - lender's Name PLUMBING FEE pQ
U. h ender.Aaarem QTY. MECHANICAL PERMIT MECHANICAL FEE
OW IcarIfy that have read this application and state that the abovelnformmlon
fD Is correct.I agree to comply with all cry and county ordinances and date laws PERMIT ISSUANCE FEES PAID:
N relating to building construction,and hereby authorize expresentativesof this
Z citytoenterupon the abwv nramtioadl property for impaction purposes. ALTER OR ADDTOMECH. Date Rfffl [#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino P
agalmth.bilities,ludgern is, A. dcxpenseswhlchmvylnanyway.mnoa AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
again 'a Gty racoma u n yr' doting of this ermlL AIRHANDLINGIINIT(OVER10,a00CFM) CONSTRUCTION TAX
Ignature of Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEA TING UNIT(TO 100,000 BTU)
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Date Reed t# _
I Irahh and Safety Cade Section2M32(a)? HEATING UNIT(OVER 100,000 BTII) TOTAL• 4
❑Yes ri No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BOILER-COMP DHP OR 100,000 BTU)
Yes n❑NoPAUD
have re.dthehazardno materials requirements underChapler 6.95 of BOILER-COMP(OVER 300,000 BTI!)
the California flealth&Safety Code,Sections 25505,75533 and 25534.I
understand that if the building does not currently have a tenant,that it lsmy NEWRESIDENTIALMECH. SQ.FT
responsibility to notify the occupant of the requirements which most be met •C�aI
priorto issuance of a Certificate of Occupancy.
Owner or authorimd agent Date TOTAL: ISSUED BY4'J"a^–aCs
OFFICE COPY