22186 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pmiect Identification , PERMIT NO.
Build Ing Address:\ i�UL,Vis •A.y ,o -h'cYSTI a
toga 3 wo RY�, - ocz�ia CA G�o�l-1 22186
Limtt�,g`S:pK¢•{�,G+a�1 1�C, one.
in^craner'eNam : LI..N°: CITY OF CUPERTINO-BUILDING DIVISION
cAPPLICATION / PERMIT
BMMINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERhETISSUANCE Pass
LICENSED CONTRACTOR'S DECLARATI LTJ �/�� X.
I hereleyafRrmchar l am licensed under provisions of Ch er9(commene RB
APPLIANCES-RESIDENTIAL JOB DESC '1'ION
IngwlthS ion7000)ofDlvleion3oftheBuelnneandProfs ksaCode,andmy T�
license is in full force and affect. PANELS
LimnseCh® LIcN `Z 7r�
Date ContraamrT
ARCHITECS DECLARATION OVER0OAMPS 11"
ODOAM
wm0ru Z I understand my plane shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA E/SQ.FT.
G(Cj Licensed Professional SIGNSELECIDU L Q�29,S 10 r cr.,
�< OWNER-BUILDER DECLARATION SPECULCM
L., 7 IhembyafBrre luitlamexemptfmmthe Contactor'sLimnmlawfmthe w....
OO ❑ following reason.(Section 70315,Business and Professions Code:Any city or gyp.M E IN U v
GZ.i"'tu -77
reartywhich rryuessa permit to mmtmct,alter,Improve,demolish,orrepalr /s
anystrocture priorto its lssuance,also requlresrheapplicant forsuch permit to POWF-RD 223 %�S.
c. file a signed statement that he is licensed pursuant to the provisions of the )
Contractor's License Law(Chapter 9(mmmencing with Seale^7000)of Dist- VALUATION
Or^ cion 3 ofthe Business and Profession Code)orthal he bexem t.at1oxman SWIMh11N LEL RIC
the basis for the alleged exemption. Any violation of Section 7m1.S by an 11TLE.�5W1 s
applicant for a permit subjects the applicant to a civil penalty of nor more than
five hundred dollars($500). NEW RFSIDFNTIAL
[—]I,as owner of the property,or my employees with wages as their sole STORKS TYPECONSTRUCTION
compensation will will dothe work and thestmaure b rot intended or offeree for
5�J O sale(Sm.704d,Business and Prerfe don Code:The Conmidoes Limine law
td$$ does not apply to an owner of property who builds or improve thereon,andO o.
who do=ssuchworkhivaelf orthrough h9ownemployess,provided that such
Improvements are not Intended oroffered forsals.If,however,the building or IOTA : _-�
improvement Issold withinonerarofcompletlon,theowner-builderwlll have
t rdeno(proving that he did eta build or improve for purpose of sale.). QTY, PLUMBING PERMIT FE OU%ANE AP
LL as owner of the property,am exclusively contraeting with Ikensed PERMIT ISSUANCE 2ii
contractors to construct the project(Sec.70K Business and Professions Code: 1$,(� '�'E
The Contractor's Limn.Law does not apply to an owner of property who
Wilds or Improves,throme,and who contracts for such P(ojeas with a ALTER-DRAIN&VENT-WATER(EA) >_
,tit actm(e)Bmnsed punuam to the ContnaoYs Limnx Law. FEE SUMMARY
LII am exempt under Sm. B&P C for this reason BACK FLOW PROTECT.DEVICE
DRAINS-FLOOR,ROOF,AREA,CONTI. SANITARY Y_ N_
Owner Use RECEB'[p
WORKMAN COMPENSATION DECLARATION �.�;S�TRAP SCHOOL TAX Y_ N_
❑[hereby affirm that I have o certificate of consent to op thereof
or RE-CEIFT N
3800,Lab of Worken'Cmmpensabonlnurance oramrtilied copy thereof(Sec. GAS G.SYSTEM-1 INGd OUTLL75 PARK FEE Y N
poli lab C.)
RE=N
P°IIiN GAS
ny EA.sYsrFM-0VER4(FA) BUILDING DI VIS ION FF.ES e
CEram aCert
lfedeopyisherebylumishad. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE D»�
r-1Certifiedcopy is filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' CREASETRM PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM pA.3007,-L Date R.C04[# —7'1(This suction need not becompleted tithe permit tefwon hundred dollars
(E100)mless.) WATER HEATER W/VENT/ELECTR �,(� ENERGYFEE Y_ N_
I mrtify that In the performance of the work for which this permit la Wood,
1 shall not employ any person In any manner n as to become subject to the WATER SYSTEM/TREATING
Workers'Compensation Laws of California.Date PAID
OZ Applicant Date Reeei t#
Z O NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you NEWRESIDENTIALPLMB. SQ.FT.
should become subject to the Workeri Compensation provisions ofthe Labor TOTCCA
U) Code,you most forthwith comply with such provisions orthts permit shall be BUIL12ING
deemed revoked.LU CONSTRUCTION LENDING AGENCY SEISMIC FEE •
Il O I hereby affirm that there is a construction lending agency for the perform, .y C ELECTRIC FEE r.CteL
Z anaofthe workforwhichb W
thls permit Issued(Sec.3097,Clv.C.) IOTA a
O O Lander'a Name PLUMBING FEE a a
L. L.ndar'e Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE .GU
U Icertlfy that l have mad this application and Asia that the above lnforma I.
O W Lscorrect.Iagree tocomply with all city and county ordinancesandmotelaws ' PERMIT ISSUANCE I C,ossa..a� FEES PAID:
CL relalingtobullding construction,and hembyauthorize representativesofthis
(.. Z eitytoenteruponthe above-mentioned pmprdyfor inpealonpurposea. ALTER OR ADDTO MECH. Date RCCCIPI#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
V
against habibtlea,judgments,cesseand expenses which may In anyway accrue AIR HANDLING UNIT ITO 10,000CFM) SUBTOTAL:
again said Ity inconsequence of the granting of this permit.
G��Q q Nexa AIR HANDLING IR'IT(OVER I0,000CFN) CONSTRUCTION TAX
(Applicant/Contractor Data EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUSM ERIALS DISCLOSURE
Wi the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IDQ000 BTL) Date Receipt#
ma alas defined by the Cup lino Munklp.I Code,Chapter 9.lZ and the ff
H,.Ithand SafetyCede Section2S532(a)i HEATING UNIT(OVER 100,000 BTU) 1 TOTALi C7 a
❑ Yes M No
Wlllthe applicant orfumm building occupant usesquipment mrdvvictre VENTILATION FAN(SINGLE RESID) a0V ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Q. lily Mavgement District? BOILER-COMP QHP OR 100,000 BTU)
r� Yes FFrom
�1 Na
4hnve read the hazaril'mv,materials qulmmenh undo Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534.I ^ r I a
understand that lithe building does not currently have a tenant,that It Ls my NEW RESIDENTIAL MECH. SQ.I7.
responsibility to notify the occupant of the requirements which most be met a �,
prior to issuance of a Certificate of Occupancy.
Ing
�
Owner or authoriseTOTAL: av
d agent Date ISSUED BY: \
1
OFFICE COPY