22067 APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building ProjectIdentification - /` - - PERMIT NO.
Building Address:'2. O L-t .5' G\6. - , 22067
A
Owner's one. CITY OF CUPERTINO-BUILDING DIVISION
vc annr' LIc.N. APPLICATION /PERMIT 7�l
v BUILDING-ELECTRICAL PMUMBING-MECHANICAL CATEGORY CO O
Arohltect/Engineer. - Llc.No
BUILDING'PERMIT INF
O'-
�TiY ` EGBCTRYC PEBMIT, dFEE
Address: PERMITISSUANCE s ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapter 9(commenc- APPLIANCESRESIDENTIAL JOB DESCRIPTION
fngwlth Seclfon7000)of Division 3ofthe BusinemandProfessionsCode,and my
license Is In full force and effect. PANUS
License Lic.# 1
e Contractor
ARCHITECTS DECLARATION 201-1000 AMPS
q�uol ZO I understand my plassshal be used as public remands. OVER1000AMP5 SQ:FT.FLOOR AREA $/SQ.FT.
j Licensed Professional SIGNS ELECTRICAL
Thoreby< ffirm OWNER-BUILDER DECLARATION
SPECIAL CIRCUIT/MCMC '
so., owingrason.(hatlam exempHro a Contractors License Law fort he
Cto11ow1ngreasonuimsaon70tw Businessmlocate Professionse=lWhnycity or TEMP,METER ORPOLE INST. '
pp catmywhich requlreaa permitrocowhtrct,alteyimprove,demolish,orrepalr
FO5 a, anystructure pdortoitslssuance,Oleo requires the applicant for such permit to POWER DEVICES
G�jj V file a signed statement that he is[lamed pursuant to the provisions of the
}gg}(( Contractor's License Law(Chapter 9(commencing with Section 7000)of Divi-
E, sion3 ofthe Business and Pmfesslons Code)orthatt be is exempVALUATIONttherefromand SWIMIMING POOL ELECTRIC //��r /'
yd the basis for the alleged exemption. Any violation of Section 7MI.5 by any OUTLETS-SWITCHES-FIXTURESl 0 O l O Q o
applicant for a permit subjectsthe applicautto a civil penalty of not morethan
five hundred dollars 1$500), L L
�j I,as owner of the property,or my employees with wages,as their sola STORIES TYPE CONSTRUCTION
compensatlon,wWdothe work and thestroclure is not Intended or offend for Ii
Osale(Sec.7064,Busbmess and Professions Code:The Contractors License Law
$ does not apply to an owner of property who builds or improves thereon,and
whodce9 such work himself orthrough his own employees,provided thisM
t avch ` OCC.GROUP RES.ATS
improvements are not intended orofferedforsale.if,however,thebullding or O"I'
improvement lssold withinoneyearofcompletlon;lheowner-builderwillhave
tlrden of proving that he did not build or improve for purpose of sale). �QTy; WMJF ^FEE. FLOODZONE APN
r�I,as owner of the property,am exclusively contracting with licensed PFRMLL ISSUANCE .�
contractors to mngruct the project(Sec.7014,Business and Professlona Code:
The ContrsRar's License Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER IEA)
builds or Improves thereon,and who contracts for such pAuosts with. ,FEB SUMMARY'
cc,[Lt[dor(s)licensed pursuantto the Contractors License Law. BACK FLOW PROTECT DEVICE
LJ I am exempt under Sec B&P C for this reason OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. - SANITARY Y_ N
. Owner ' Data— RECEIPT I
DECLARATION
WORKMAN COMPENSATION DECLARFMTURES PER TRAP SCHOOL TAX Y N
"0L hereby affirm that I have a certificate of consent to opytheure,ora RECEI r N
3800,Lab of Workere'Comperuationlrmurance ora certified ropythereof(Sec, GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Lab CJ ,
Policy a RECEIPT#
Com an GAS EA.SYSTEM-0OVER BUILDING DIVISION FEES
e e copy is filed haroby
the city GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
' MCemled copy is(lard with the city inspection division. ^'
i
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASE TRAP PAID
INSURANCE
COMPENSATION e 1•L
(Thlesection need CnetO be completed the for one hundred dollars SEWER-SANITARY-STORM EA 200FT Date Remi t#
($100)or less.) - WATER HEATER W/VENT/13.ECTR ENERGYFEE Y_ N
I mrtify that N the performance of the work for which thin permit b issued, -
I shall not employ any person in any manner so as,to become subject to the WATER SYSTEM/TREATING
rs Compensation Laws of California.Date PAID
-
z
0 Z Applicant NEW RESIDENTIAL PLMB. SOFT. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
,should become subject to the Workers'Compeneatfon provisions of the Labor TOTAL:
fq Code,you must forthwith comply with such provisions or this permit shall be NG E
LU 9 deemed revoked.
CONSTRUCTION LENDING AGENCY BUILDISEISMIC.FEE
Il [hereby affirmthat there L+amwtructlon lcndingagency forth perform- ELECTRIC FEE
7O auceofthe work for which this permit is Issued(Sec.3097,Cls.C.) TOTAL
Under.Name PLUMBING FEE
LL H Lenders Addresn QTY.." ME64ANICAL PERMIT "`i EEi'`
O W Imdilythatl have read thisapplicaHonand abdothattheabove information MECHANICAL FEE
M lecmrrect.I agree to complywllh all city and countyordinances and state laws PERMITISSUANCE FEES PAID:
} N relating to building construction,and hereby authorixeovpresentalves ofthIs
city to enter upon the above-martfoned property for impandon purposes. ALTER OR ADD TO MECH.
Z (We)agree to save,Indemnify an of keep harmless the City of Cupertino Date 'Receipt#
V against liabilities,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,000 CFM) .SUBTOTAL:
agalnt Id Ciry n uence of the granting of this permit./• PIR HANDLING UNIT(OVER IO,000CFM) CONSTRUCTION TAX
ay
gnature of Applicant/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stere or hand In havardoua HEATING UNIT(10 100,000 BTU) Date - Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
I ealth and Safety Code Section 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL. y
❑'Yes. n No
Will the applicant or future building occupant use equipment or devices VFNIILATION FAN(SINGLE RESID) ISSUANCEDATE-
whichemithamodousaircontamimntsaadefinedbytheBayArea Air -
Quality Management District? BOILER-COMP CEI'OR 100,000 BTU) y'"?(
4 Yes No �Y
have read the hazy ms materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) Ij jn,
the California Health&Safety Code,Sections 8505,75533 and 25536.I dl'
understa nd that if the building does not comendy have a tenant,that it is my NEW RESIDENTIAL MECH. SQJ`T s,7(
responsibility to notify the occupant of the requirements which must be mot -'
prior to lssuanceofa Certiti ate of(kxvpan
RltMn
Owner ora thorimd agent Data
TOTAL: ISSUIiU OY-�� �x/YT`s-/"' �
OFFICE COPY