22502 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY-
Building Project Identification - PERMIT NO.
B":Id ing Addren: C CT- Cu RT'au C C
. 115z 5 SUtJSL-T . spRLu t ( ,. A g501 Y-• 2'2502•
• •.Owner arae: - - Ph.c%
,*%(u— LA" IA t3. C�eB)-z�3=�'43 CITY OFCUPERTINO-BUILDINGDIVISION � /
Cuntrachn's Nays: Etc.No: APPLICATION /PERMIT '
BUfLDING-ELEC7RICALPLUMBING-MWHAMCAL CATEGORY CONTROLM '
Architect/Engineer. Lle.No:
. - • '. t' i' r .' U ^o .t t t "" " ''',.BUILDING PERMIT INFO' 1
,. QTY ,� - •ELECTRIC PERMIT I FEE
• -
Add,.,: - l PERMIT ISSUANCE t '❑
LICENSED CONTRACTOR'S DECLARATION
I hereby aftirmthat l am licensed under prowslon9a(Chapter9(commenc. APPLIANCESRESIDENTAL JOB DFSCRIPTIDN
Ingwlth5ect1on70(XOof DlVeslon3o([heguslnemend ProlnalonsCode,and my -
license Is In full form and effect. PANELS '
Licanse Claes Lic
Date Contractor
ARCHITECTS DECLARATION
201-1000 AMPS l
re Iunderstand my plans shall be used as public records OVERIOOOAMPS SQ.F�RI EA $/SQ.FT.,
OG E N
Licensed Professional SIGNS ELECTRICAL x
�6 OWNER-BUILDER DECLARATION SPFCIALCIRCUIT/MISC- ) 1 ' TER
� X�
7H, 4 Iherebyaffirm that l am exempt from the Contractors Licerue Law for the V H
o following reason.(Section 7001.5,Business and Professions Code:Any city or
rosalteu, TEMP.METER ORIOLE INST. '
lrg countyanystmhmph droit, rmRe,auorquimtheapmvntforllah, er ttr
$ any atmcturctate tents Cut he Is licensed pursuant to the provisions
to )OWER DEVICES
•ryE Elle o signed statement
cens eLathat he es licensed momism it the Pon 700D) of the ,
80p., ContraftheBkenx lad Profs ionsCom)orthag withSectionDivl- '
G SWIMMING POOL ELECTRIC
SOS sren3o(the6uslnem and Profemlons Code)orthat he is ex¢mpttherefromand "� "'�•' ' VACUA ON`
the bases for the alleged exemption. Any violation of Section 70'015 by any ^�
G ppllmatfor a permit subjectsthe applicant to a civil penalty of not rrore than OIITLETSSWITCIiESHXfURFS P / ��G:�'�'"
EE o fve undred dollars
as owner of the property, NEW RESIDEMIIAL ELECTR SQ.FI'. STORIES TYPECON5IRUCTION'
�n {�,�'e p perry,or my employees with wages r their door
u fnpensatlon,wllldo the work and the structure la not intended or offered for
q sale(Sec 7044,Ifisheas and Professions Code:The Contractors License law
(IjF$•$ does not apply to an owner of property who Wilds or improves thereon,and OC
E; who does such work himself or through his own employees,provided that such C.GROUP RFS.UNITS
Improvements are not intended oroffered forsale.If,however,lhebullding or T07
improvement issold withinoneycarofcompleiantheowner-buRderwill have
tkelzurden of proving that he did nor build or Improve for purpose of sale.). QTY. ,iiPLUMBINGTERIVIFF •, i i•EE ' FLOODTONE „ APN
11 L a9 owner of the properly,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to ronstruct the project(Sec.70K Business and Professions Code: -
The Contractor's License Law don nor apply to an owner of property who -
Wilds or Improves thereon, and who contracts for such p(ojecia with a ALTER-DRAIN&VENT-WATER(EA)
se,,➢➢._IT.&or(.)licensed pursuant to the Contractor's License Law. - — ",FEE'SUMMARY;'',s•' r
'
L_I I am exempt under Sec B&P C for this reason HACK FLOW PROTECT.DEVICE
UT1.11F FEES
DRAINS.FLOOR ROOF,AREA,COND. SANITARY Y_ N
Own • — rrn Dace RCCDPI'p
i� ORKMAN COMPENSATION DECLARATION FU(TURFS-PER TRAP SCHOOLTAK Y N
01 hereby.Burn that I have a certNra c of consent to op thereof
ora RECEIPT N
certl(Iwte of Workers'Campensatlonlvurance oracertifled copy thereof(Sec. GAS FA.SYSTEM-1 INCAOUTLM- PARK FEE Y N
' 3800,Lab C3 .
Policy X GAS FA.SYS[At-cam 4(EA) - RECEF'f p
Com any - BUILDING DIVISION FEES
ffCertined copy Is hereby furnished. ' PLANCHECKFEE
F-1Ceelified copy es filed with the city Inspection WASTE INTFRCGITOR'
ion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' - GREASETRAP PAID L.O
COMPENSATION INSURANCESEWER-SANITARY STORM EA 200FT -DRte RCCCI 1#
QMssection need not be completed if the permit b for one hundred dallan
0100)orina.) WATFRIMATTE W/VENT/ELECTR ENERGYFEE Y .N
'I certify that in the performance of the work forwhich this permit is tsaued,
I shall not employ any person in any manner so as;to become subjert to the WAm SYsrEm/TREATiNd .
Worked Compensation laws of California. Date PAID
z Z AppliNOTICE
NEW RESIDENTIAL PLMB. SQ.Pf, Date Remi t#
Z O NOTICEco esubpettothe Workers
Compensathis ion
Certificate Exemption,Labor skald bemm¢subject to the Workers'Compensation provhbns of the Labor TOTAL'
ir fq Cade,you at forthwith comply with such provisions or this permits hall be BUILDING FEE —�
W 9 deemed revoked. - .
0. C CONSTRUCTION LENDING lending AGENCY SEISMIC FEE
Z eof ebythe affirm Mat iherebammt Is Issud(Sec. agency f,C.) perform _ TOTAL: ELECTRIC FEE
M once of the work for which this permit Is Issued(Sec.3097;Cu,C.)
U O Lenders Name - - - - PLUMBING FEE
IL H ]enders Addmx QTY. ',t� 'MECHANICAL,PERMIT '1 • FEE MECHANICAL FEE
O W •I certifythat l have mad thisappIleationand gatethattheabov¢information -
Iscomet.I agree tocomplywilh all city and county ordinances and nate laws PERMIT ISSUANCE FEES PAID:
} O' relati ng to build Ing commudion,and hereby authorie repreaentativn of this -
(— Z city to enter upon the above-mentioned property for Inspection purposes. ALTER OR ADD TO MECH. DR[C RCCCI I#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino ,
against liabiWiei,judgments,cost,and expert.which may In anywayacaue AIR HANDLING UNIT(TO 10,0D0(FM) I SUBTOTAL:
against said City in consequence of the gnuding of this permib
AIR HANDLING UNIT(OVER10,000 CFM) CONSTRUCTION TAX
( Signatu of Applicant/Contractor ' Date EXHAUST HOOD(W/DUCT) CONSTRUCTION-TAX PAF �E�
HAZARDOUS MATERIALS DISCLOSURE r L
Will the appllcant or future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU) Date RCCCI f#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
.Health and Safety Coda Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) TOT L
❑ Yes MN. _
Willtheapplicad orfuturebeiidingoccupant useequlpmentordevim VEMILATION FAN(SINGLE RESID). ^ SV)DJCE DATE
which emit hazardous air contaminants as defined by the Bay Ares Air f /'�_.1"
Quality Management District? - BOILER-COMP OM OR 100,000 BTU)
❑Yn n No 91
Ihaverria malt&&Safety
notarises tions em05,2553 and 25534.
1 of BOILCR-COMP(OVER IN,000 BTU) will,• 1 Q 19
the California Flealth&Safety Code,Sections 25505,25573 and 75534. 1 11 v
unprmsundthat rally
thedingdoes of t erequinerants which thath met NEW RESIDENTIAL MECFI. :Q.Ff. - ',
r prior
to Issue ce of aCeheompantccupanequlrement9 which must be met 1Jt('$t ll�U
prior to Issuance o(a Certificate of Occupancy. QIIY Ur CU \!&�
Owner or awhoded agent Date - -
TOTAL: ISSUED BY:
. OFFICE COPY- .
INS
ill SPIN