22417 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildin Prm'en Identification PERMTNO.
Binding Addrey�: eSsAima*z(530 3 22417
one: p A
neva .nm:9, 4 ' ) Q r a"ildCITY OF CUPERTINO-BUILDING DIVISION
Cotru _tors me: Lie.No: APPLICATION / PERMIT - -1 I
�y
Ili/
JM GO/O (`S 7 JA 9 BUILDING-ELECTRICALPLUMBING-MECHAMCAL CATEGORY CONTROL
rc [ted/Engineer. Lic.Na:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE 2 ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am Ilmosed under provisions of Chapter 9(commere, APPIJANCESRESIDENTIAL JOB DESCRIPTION
ng with Section 7000)of Division 3 ofthe Busions and ProfessionsCods,and my
license is in full force and effect (y PANELS
License Class(./o S -2;11 f13 31�^ii`�B•�—,I_Yl' 1
Date Contractor `}/
ARCHITECPS DECLARATION 701-1000 AMPS
re 7 I understand my plans shall be used as public records. OVER 1000 AMPS SQ.FT.FLOOR AREA $/SQ.FT.
OO
Licensed Proseatiml SIGNSELECTRICAL A E D 1
Itiern6 c. OWNEReBUILDER DECLARATION iVI ? U T E
w SPECLILCIRCUIT/MISC
F 7 owing reason.
(
that l am 31.5,Bxempt fromass a Contractor's License Law for the
�g..Q followfngreasonuimsa e7 tt cminessand Professione=le hnydtyor TEMP. ORIOLE[NST.
, f'W countywhkh requlresa perMttocontrue[,ilteq improve,demollsh,orrepalr ✓1 /1
44 d anystrudure priorto its Issuance,also requiresthe appBant forsuch permit to POWER DEVICES �V /� 7 /
Eyril y,f`1 O file a signed statement that he Is licensed pursuant to the provlsbns of the
Q 3"� Cmdractor'sLicense Law(Chapter9(comrnencing with Section 7000)of Dirt. SWIMMING POOL ELECTRIC VALUATION
O sion3ofthe Business and Professions Code)orthat he Is exempttherefromand 11 L
O the basis for the alleged exemption. Any violation of Section 70315 by im UTLETSSWITCHESHXTURES
CC55 applicantfora permit subjedstheapplkanttoa civil penalty of nM morethan - f
five hundred dollars(S500). NEWRLSIDENI7ALELECTR SQ.FT. STORIES TYPE CONSTkUCTION
m ❑1,as owner of the property,or my employees with wages as their sok
comperes.Hon,will do the work,and the structure is not intended or offered for
Dsale(Sec.7044,Business and Profdslons Code:The Contractors License Law
$ does net apply to an owner of property who Wilds or improves thereon,and OCC.GROUP RES.UNITS
who docs such work himself orthrough hie own employees,provided that such
improvements are not Intended oroffered forsals.If,however,thebuilding or TOT
i provementbsoldwithinoneyearofcompldiogtheowner-WBderwillhave s
i rden of proving that he did net build or improve for purpose ofsale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
r3 L as owner of the property,am exclusively=trading with licensed PERMITISSUANCE
eo drsdoes to construct the project(Sec.7044,Business and Profession Code:
The Contractor's License Law does not apply to an owner of property who
Wilds or Improves thereon, and who commea for such p,*va;with a ALTER-DRAIN&VENT-WATER(EA)
co1tt..[[ador(s)licensed pursuant to the Contractor's License Law. FEE SUMMARY
In am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT x
WORKMAN COMPENSATION DECLARATION FIX.[URESPER . SCHOOLTAX Y_ N_
541 hereby affirm that I have a certificate of consent to seI-insure,ora RECEIPT x
certificate ofWmrkers Compensation Insurance me certified cupythereo((Sec. GAS EA.SYSTEM-1 INCA OLITLETS PARK FEE Y N_
3800,Lsb C.) — RECEIxfx
Policy p GAS F.A.SYSTEM-OVER 4(FA)
Com any BUILDING DIVISION FEES
ruled copy is,hereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR PLANC14ECKFEE
,y ied ropy Is filed with the city Impection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA."FT. Date RCCCI I#
(This section need not be completed lithe permit Is forme hundred dollars
($100)or lose.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I dirtily that in the performance mf the week forwhich this permit Is Issued,
I shall not employ any person in any manner so as to become subject to the WATER SYSTEM/TREATING
Workers Compensation Laws of California. Date PAID
O Z Applicant N13WRESIDENTIALPLMB. SQ.FT. Date Recef t#
Z O NODCETOAPPLICANT:lf,aftermakingthie Cenlficateof Exemption,you
should become subject to the Workers Compensation provisionsof the Labor TOTAL:
F" N Code,you=atforthwith comply with such provedone orthie permit shall be BUILDING FEE
K deemed revoked.
Ill — CONSTRUCTION LENDING AGENCY SEISMIC FEE
a [hereby affirm that there Is a contmdlon lendingagency forthe perform TOTAL:
ELECTRICFEE
7 Z ante ofthe work forwhlchthls permit Is Issund(Sec.3097,C1v.C.) PLUMBING FEE
I, 0
(.ender.Name
LL r Lerders Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
U Idirtifythatl have read thlsappllcationand statethat the above Information
O W Ismrred.I agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
r a relating to building construction,and hereby authorize representatives o(thle
H 2 city to enter upon the above-mentioned property for inspection purposes. ALTERORADDTOMECH. Date Refeip[#
(We)agree to save,Indemnify an d keep harmless the City of Cupertino
L) againthabillties judgments,dwarindexpeneeswhichmaylnanywsya¢rue AIR HANDLING UNIT CTO 10,000 CFM) SUBTOTAL:
against said Cd n endiof Ne granting ofthi.permit CONSTRUCTION TAX
AIR HANDW NG UNIT(OVER t 0,000CFM)
CONSTRUCTION TAX PAID:
Ygruture ppl' nt/Contractor t EXHAUS"f HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or ba cad le hazardom HEATING UNIT(TO 100,000 BTU) Date Reeei t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 1,and the
Health and Safety Code Section 25537(.)? HEATING UNIT(OVER 100,000 BTU) TOTAL: t
M Yea ri No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit h.zanlous air contaminants as defined by the Bay Arca Air
Quality Management Distne? BOFLFR-COMP DEEP OR 100,IXID BTU) a �m
4Yes ❑❑No
haverndthahaz Sal matde,Secione2m05, under 25533 aChapter.1 of BOILER-COMP(OVER100,000 BTU) ��� 9^^
the California Health&Safety Code,not currently
ntly have a tenantnd that 1
enderstandthat ifthethedingdoes not emiltuyevents which
that b iset NEW RESIDENTIAL MCCH. SQ.FT Cam,�j
responsibility to nollty the occupant of the rcquirementswhich must be met (aax`y s,Vaa�
prior to issuance of a Certificate of Occupancy. MY Ca
Owner or authorized agent Date
TOTAL: ISSUED BY.. ��nl
OFFICE COPY