22245 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project ldentlfleatloe PERMIT NO.
Build ing Add a,: ^f")frI /I r
VQ 1( 2224 '51
oversea
one;
.mors r CITY OF CUPERTINO-BUILDING DIVISION —/(- 7/
c°"tracter'.Nane: Lie.No: APPLICATION 1 PERMIT
p��yNBUILDING-ELECnUCAI PLUMBING-MECHAMCAI. CATEGORY CONTROp —L
AmMiect/Engineer. d Jr-aa xl\�' Lle.No: l
V C 9 Err ELECTRIC PERMIT FEEBUILDING PERMIT INFO
(
Addranc: jqq E• •� ^`', QD.S.J_rg5jl PERMIT ISSUANCE DY qq
•Q0r_'W . ❑ ❑
LICENSED CONTRACTOR'S DECLARATION r
I hereby affirm that l am licensed under provisions of Chapter 9(commenc APPLIANCES-RESIDENTIAL JOB DFSCRR'DON
ingwith Seaton 7000)ol Dlvlsion3ofthe Businsesand I micoaElonsCode,and my
rensese'Clam f rce<ndLt..M X3' 4(k �1 PANES
Data Contractor
ARCHITECTS DECLARATION 201-IODDAMPS
6 z2. I understand ery phru•hag be used as public records. OVER 1(100 AMPS �f.17. R AREA $/SQ.FT.
IoFf
k Licensed Professional SIGNS ELECTRICAL - iD N
t< OWNER-BUILDER DECLARATION SPECIALCIRCNT/MLSC UTE R
'?" 1herebyaflrm that l am exempt from the Contractor's License Law for the
Q follawingreason.(Seolon7011.5,Business Professions Code:Any city or /�/ /^/
0Z^ c°untyng masegWreaa n7031 ,Bruins aid Professions
emlCode:Any city r Ta'1P.METER ORI'OI.E INS!. I/(�
anystructum prior to its lsuaner,atsorequires lheappliant for such permit to (OWER DEVICES
r Rte a signed statement that he is liaesed pursuant to the provisions of the
OwF Commenc^s License Law(Cha pter 9(commencing with Section 7000)of Divi- gWDx{,\gNG POOL ELECTRIC VALTI N
UA
BOJ slon 3 of the Busicessand Prefixed..Cede)or that he V exempt there(romaM oD TQ
ES Sn....3333 the basis for the alleged exemption. Any violation of Section 70115 by any U
« appllantfora permitsubjectstheapplicantto.civil penalty elect..than oOVILETSSWITCHFSFDiTURES TOP
By hundred della.(&500).
I,as owner of the roc NEW RFSIDENTIAI.ELECTRSQFI', STORIES TYPE CONSTRUCTION
property,and
my employees is
ars their
rot.Sec, 0Kw0ldolhework endthestructureh not Intended or offered for
Q dole(Sec.apply
to an owner
fgropeProfessions;Codi The Contractor.Liame Law
S4 doe not apply work owner of propertywhonemplo improveprovided that
uch OCC.GROUP RES UNITS
C. whodoeents such amrkhimself edoor rofferedugh own employees,I,however,theedthat goo
Improvements intended pimia.theer-bu Uderwllingm TOTAL: ,0
Improvement bsold wlthlnoneyearefcomploleRtheownervbu0derwlll have
fla.liurden of proving that he did not build or impmve for purpose of sale.). QTY. PLUMBING PERMIT FEE FLOOD TONE APN
Lj 4 a•owner of the property,am exclusively contracting with licensed pFRMpp ISSUANCE
contractors to construct the Project(Sec.7064,Business and Professions Code:
The Contexctori License Taw doe not apply to an owner of property who ALTEtARAIN&VENT-WATT72(EA)
bulMs or Improves thereon,and who cent.cts for such Pm Qejewith a FEE SUMMARY
ixpa4actor(s)R¢nsed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
LJ I•m exempt under Sec. B&P C for this reason
Owner GRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Date RECEIPT M
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certificate of consent to self-Insure,or FI(Tl1RES PER TRAP SCIBOOL TAX Y_ N_a RECEBT M
cenifiate mWorkent Comperuation insurance or a certified copy thereof(Sec. GAS RLI.SYSTEM-1 WC.40UTLETS PARK FEE Y N
P80q LMbC.) 0 ��` RECEITX
Co n g GAS F.A.SYSTEM-OVRR4 LEA)
kaY T_'�' � t ( BUILDINGDIVISIONITES
ertiRed copy Is herebyfurnished.thecity
GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE
�ertitled copy or(fled with the dty Inspection division.
CERTIFICATE OF INEVIPTION FROM WORKERS' GREASE TRAP PAID 6�1�)
COMPENSATION INSURANCE SEWER-SANITARY-STORM RA,200FE Date Remi t#
(Thi•section need not be completed if the permit or fore.hundred dollars
rectify
that
WATER HEATER W/VENT/ELECT'R ENERGY FEE Y N
Icony Mato the person In
tis•work(o astobco which permit is issued,
I.hall not employ any Person In any mannerso u to become subject to the WATER SYSTEM/TREATING
Workerd Compensation Laws of California.Date - PAID
ZQ NOTICETO APPLICANT-.
IL maki
ager ng this CertlOate of Exemption,you NEW RESIDENTIAL PLMB. SQFf. Dale Rem #
i t
should become subject to the Wmkam'Comperuation pmvlaioro of the tabor TOTAL:
W Code,you must forthwith cemply with such provisions or thi•psmut hall be O
> deemed revoked. BUILDING EZS`
CL C CONSTRUCTION LENDING AGENCY SEISMIC ITE S2
Ihembyafinotharlhere ieacomtruction kndingagenq(urine perform TOTAL: ELEC'T'RIC FEE . 00
Z arm of the work for which this permit is l•sued(Sec.3097,Civ.C.)
U 0 Tender'sNam• PLUMBING FEE
LL I– Lender'sAddree QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Ianifythatl have read thisapphation and statethattheaboveinformatlen
G bmun
comou.logreetocomplywith allcityand tyordinances•ul state laws PERMIT ISSUANCE FEES PAID:
N relating tobulldingconstruction,and herebyauthorlu representatives of this
H Z citytoe"lerupon the above-mentioned property for inspection purposes. ALTER OR ADD TO MECH.
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino Date Receipt#
galetlublliaes,jodgment cestsande chmxyinanywayacerue AIR HANDLING UNIT 10,000 CFM) SUBTOTAL:
aWUald Clty In con \ Ie permit. AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor r Data ErHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the appllant or future building occupant afore or handle hazardous HEATING UMT(TO 100,000BTU) Date Recei t#
material as defined by the Cupertino Municipal Cede,Chapter 9.1 2,and the
I and Safety Code Section 25532(.)7 HEATING UMT(OVER 100,000 BTU) TOTAL:
rI Yes No
ill theappllard o,fu.rebuildingompart use equipment ordevicea VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air conta Mnants a•defined by the Bay Area Air
P�
Quality Management District? BOILER-COMP OLTP OR 100,11(0 BTU) P"
4 Ye Q No
have read the hazy oustwterals rcefulrements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) JUL �Q(},t
981
the California I Icalth&Safety Code,Seo Ions 25505,25533 and 25534.I
understand that lithe building does not currently have a tenant,that it or my NEW RESIDENTIAL MECH. SQ.FT
responsibility bllityto of a theoccupantntofthe requirements which must be mM
priortooftlythe cu ant ocupa fthe req -
Owner or authorlud agent Date ISSUED BY; O ✓
TOTAL:
OFFICE COPY