22204 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Address: 22204
753S W 4,�FbYz car 2i inir�
neva ante: one: p
JaHnJc� u08 7V, 2. 1y CITY OFCUPERTINO-BUILDING DIVISION
Contradols Name: Llc.No:
APPLICATION I PERMIT
OWA/E/C. BUILDING-ELECTRICAL-PLUMBINGMECHANICAL CATEGORYCONTROL#
Architect/Engineer. Lic.No;
QTY ELECTRICPERMFF FEEBUILDING PERMIT INFO
Address PERMITISSUANCE TZ ,,rr����W N �Y
LICENSED CONTRACTOR'S DECLARATION �5 Y
I Mrabyattlamlt¢eorder provbiorrof Chaperen APPLANCSRESIDENML JO�B�DESCRIPTION
lnSectio.7000)alDlv3.ftheBudnessandProfeadonaCod.,.d
license 1s In force and ficet. PANELS
LtcensClassv- --- Lic.#
Date Contactor UP TO 2DO A95
ARCHITECPS DECLARATION 201-I000 AMPS
Q�v re 7z I understand my plans shall oe used u public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
E (C� Limned Predeadmul SIGNSELECTRICAL -In 0 L—/I1,IIL,�' ��d.•T
ku OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MLSC x �Sl (J v l a-•
2F Ihereby affirmlhatI am exempt from the Contractors License Law for the �/
qq following reason.(Section 7031.5,Business and Professions Code:Any city or
Fe'cy county which rcquimsa permit tocerestruct,alter,Improve,demolish,orrepair TEMP.METER OR POLE INST.
any etndurc prlartolb Issuance,alsorequlrestheapplicant for each permit to
r�C file a signed statement the he is licensed pursuant to the provision of the POWER DEVICES
Contractor'.License 1-0 lew(Cha erg(mmmencin withSection7000)ofDIv1-�n Pt B SWIMMING POOL ELECTRIC
slon3olthe Budnesaandlsrofesslon Code)orthet heb exemptthercfromand �ts�..�
a �L —`L �" VALUATION
o
the basis for the alleged exemption. Any violation of Section 70315 by any �U' OIITLETSSWTTCHESFIMURES a-•CJ 1 J.Q1
S .•M,
A applicant fora permit aobj is theappllcanl toa civil penalty d room nrc than
m�u !i undyed dollars($50(). NEW RESIDGN77AL ELFLTR SQ.FT.
�n 1,as owner of the property,or my employees with wages as their soleI 'v „ V�IF� [)PEC TION
compensation,wBed ldo twcrkandthestrucmre is not intended or offend for
R O sale(Sec.70K Busineas ami Profession Code:The Contradols License Law
does not apply to an owner ofCompany who build.orImproves lhercon,and
n• whodce.suchworkhirmalforthrough hisownemployees,provided that such W 4W1' I'q' T
improvements are not intended oroffned forsale.lEhoweveplhebuildingor TOTAL:
Improvement issold withinoneyearofcompletion,the ownenbullderwlll have O /
tll,psrcien of proving that he did not build or improve for purpose of sale.). QTY. PLUMBING PERMIT FEE
\\ L_jj L as owner of the property,am exclusively contracting with licensed ctPERMIT ISSUANCE
contractors to mmtmd the project(Sec 7046,Business and Profession Code: 2 m
TM
Contractor's License Law does not to an owner of property who ALTER-DRAIN&VENT-WATER(EA) GlO
Wad.or improves thereon,and who contracts for such pipjects with a FEE SUMMARY
contradorW licensed pursuant to the Contradols License Law. BACK FLOW PROTECT.DEVICE
[:]I am exc!l under Sec. B&P C for thla reason
OUTSIDE FEES
�. DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N_
De - RECEIPT_ N#
iRIN COM SATION DECLARATION SCHOOL TAX Y N
❑I her 0R m that I have a certificate D consent to self-Insure,ora l TURES'PER TRAP 2u�
certificate ofWorkers'CompenaHon Insurance m a&Alfkd copy thereof(Sac. - RECEIPT#
38W,Iab C.) GAS EA.SYSfEM.1 INCAOUTLEIS PARK FEE V N_
Pol try# - RECEIPT#
GAS EA.SYSTEM-OVER d(EA)Co������mypppppaaaaaanay BUILDING DIVISION FEES
Rcertlfied copy Is herebyth the city GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b Isere with the city inspection dlvblon.
CERTIFICATE OF E%EMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA XIOFI. Date RCcei IN a�
(Thlssedion need not be complded If the permit b for one hundred dollars
a100)nrfe„a WATER HEATERW/VENT/ELECTR ENERGYFEE Y N
I certilythat Nthe performance of the work torwhlch fhb croon is issued,
I shall not employ any perso In any manner n as to b ted
Worker'Compensation larf(SR .Dale WATER SYSTEM/TREATING PAID
0 Z Applicant NEW RESIDENTIAL PLMB. SQFr. Date Recei t#
Z O N0110EIO APPLICAp .],after ma king this Certificate of Exemption,you
should become sub, the Workers'Compensation provision of the Labor TOTAL:
CC
N Code,you moat forthwith comply withauch provision orthis permit shall be BUILDING ••E
LU j decmod revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE 1
T hereby affirmtMt there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE L
M Z ante of the work for which this permit is Issued(Sec.3097,Civ,C.)
u O Lender's Name PLUMBING FEE
I— Lendaea Addrew QTY. MEC14ANICAL PERMIT FEE
O W Icertlfylhat l have read this epplicationand stxtethat the above information ^ ,..mss MECHANICAL FEE a
IL Iscerred.l.gree to comply with act etyand ceuntyordlnanceaand pate laws I PERMIT ISSUANCE aC..W FEES PAID:
relatingtobulldingcona
t <tion,and hereby authorize reprueentativesofthia
N
F city to enter upon the above-mentioned property for impaction purposes. ALTINORADDMMECH.
? Me)agree to save,Indemnify an d keep harMess the City of Cupertino Date Reeel t#
V against liabilities,judgmenta,coesand expenses which may in any wayacerue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City In consequence of the panting of this permit AIR FIANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatureof Applicant/Contractor Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Wllltheapplicant or future building occupant store or handle hazardous HEATING UNIT(TO 300,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Hes llh and Safety codion 25532(a)7 HEATING UNIT COVER 100,000 BTU) TOTAL:
Yes tNo
❑
Witlthe Applicant or future buildingxmpant use equipment ordevices VEMDLATION FAN(SINGLE RFSID) ISSUANCE DATE
which cent Mrardous air contaminants as defined by the Bay Area Air
Quality Management C�jd d7 BOILER.COMP IMP OR 100,M BTU)
qYrs 12(J No
MY mea the M1 oety Code,ls Sections
255,2553 and
8.95 of BOILER-COMP(OVFA 300,000 BTU) kjodn
the Gltand that
If t h&Safety Code,Section 5505,have
A i and 25534.I ��''"-1Y11i
understand thatilthe building does not currently have•tenant that It is my NEW RESIDLNTfAI.MECH. SQ.FT.
responsibility to ndlfy he occupant of the requirements which at be met MAY 9 � 1
prior to Issuance of rtlficateof Occupancy. a s�s:Jl �� pip
Owncror autM1 da pat OTAL: IggOpD f. ,. .
W
OFFICE COPY