22850 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
BuilditijiPromd Identification PERMITNO.
Building.Add xas: 0 22850
o- ZOO ea . �ALcoSP 2° .3
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L\/ti\'T�,t Y�`ILQL�LSJ CITY OF CUPERTINO-BUILDING DIVISION q p
Contractors Name: C-Its Uc.No: APPLICATION /PERMIT l
T LCA" T St[aa Sit 1 BUILDING-ELECTRICALPLUMSING-MECHANICAL CATEGORY CONTROL N
Architect/Engineer. Lk.No:
QTY
ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: 112'4 CLNt"V/LST_ L✓ . l'.aa.a.L.rWT
PERMIT ISSUANCE .QU ❑
LICENSED CONTRACTOR'S DECLARATION
I MhS afn7DOO)tlamlkenxd under eBuMmmandso(ChaptsCode, menc APPI]ANCESRESIDENIIAL JOB DESCRB'TION
licer.hSMbn7000)ol Diviton3o(the Butressand PmfmlonsCode,and my
license b In full f r�ceVan)bdfeR_-' IT TO 2W AMPS
�� PANELS
Licenx Class Lk.p • \/
Date Contrato
ARCHITECT' D CLARATION OVEMI-I000AMI"'
W C77 lundcmtandmyphmshaBbeuwdupubhcre rds. OVERIWO AMT'S �Fq CpiM1aG� ' $/SQ.FT.
}a `j
Licensed Professional ' 9GNS ELFLTRICAL O pL CU SVT) E
<Q OWNER-BUILDER DECLARATION
G SI'FGIALCDtCUIT/M15C
702F.� following
Fp, � affirm Rutlamexempt fromthe Contractor's Llanx lnw fmthe
reason.6etllon 7031 S,Business and PmfmbnsCode:Any try or requiresTEMP.METER OR POLE INST. /
county which requires a permit to construct,alter,Impmve,derolbh.or repair J 6
F 4.'ci anystmcture prior to Its'ance,also requireathe applicant forsuch permit to POWER DEVICES
U wfile a signed statement that he b
licensed pursuant to the provisions of the
RnContractors License la (Cha pter9(rommentlng with Section 7000)of Divi- SWN(MING POOL ELECTRIC VgLUA
F O sion3ofthe Businmand Profmbm Code)orthathebeumpt therefromand
p Q 5 the basis for the alleged exemption. Any violation of Se tion 70315 by any OUTLETSSWITCHESFIXRJRES 0
appBcant(ora permit subjects the applicant toativll penalty dnot rrorethan
p. five hundred doll..($500). NEW RESIDENTIAL ELECTR SQ.FF. STORIES TYPE CONSTRUCTION
7 6 ❑I,as owner of the property,or my employees with wages as their sok
compensation,w111dothe work,ande icamic are is not Intended or offend for
.p sale(Sec.7014,Bualness and Pr fmions Code:The Contractors License law
$$ don not apply to an owner of property who builds or improves thereon,and OCC.GROUP RFS.UMTS
who does such work himselforthmagh his own employees,provided that such
improvements am not intended or offered for sale.If,however,the building or TOTAL: Q-UD
improvement is sold within one yearofcompltion,the owner-Wilderwlil have
tos-I,u,d an of proving that he did not build or improve for purpose of wleJ. QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
"L as owner of the property,am exclusively contracting with licensed PERMIT ISSUANCE
contractors to construct the project(Sec.7014,Business and Pm(mbru Code:
The Contractor's License Law don net apply to an owner of property,who ALTER-DRAIN&VENT-WATER(EA)
Wilds or Improves thereon,and who contracts for such p,.ojets with a FEE SUMMARY
o,�1BB�(ator(s)Ilansed pumusnt to the Contractors Licenx Law. gAIX FLOW PROTECT.DEVICE
c Ln I am exempt under Sec B&P C for this reason
OUTSIDE FEES
DRAINS FLOOR,ROOF,AREA,CONTI. SANITARY Y_ N_
Owner Date RECEB
❑1 here
WORKMAN COMPENSATION DECLARATION FIXTURES— TRAP SCHOOLTAX Y_ N
by affirm that I have a certificate of consent to self-Insure,ora RECEIPT N
cenifirateofWorke,s Compensation Insurance ma certified copythereof(Sec. GAS EA.SYSTEM-11NCA OUTLETS PARK FIE Y_ N_
3800,Lab C.)
Policy N RECE PT N
S O
Co any GAFA.SYSTFM- VER 4(EA) BUILDING DIVISI ON FB ES
EcZified copy b hereby furnished. GREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy Is filed with the city inspection division.
CERTIFICATE OF E(FM PTION FROM WOR KERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 700FT Date Rccei t#
(This section need out be completed If the permit b for one hundred dollars
($1W)or less.) I WATER HEATER W/VENT/ELECTR ENERGYFEE Y_ N_
I certify that In the performance ofthe work forwNch this permit Is busied,
I shall not employ any person In any manner x as to bee res b�ect to the WATER SYSTI7d/TREATING
Workers Com aatlon Lalzb Ifif.Da u PAID
0 Z Applicant T NEW RESIDENTIAL PLMIE SQFI. Date Rett'1 f#
Z O I NOITCE TO ICAM:If after .1 this Certificate of Exemption,you
should become bject to th'Wor m'Compensatlon provisions of the Labor TOTAL:
CC to , Code,ymunwstforthwlthco withsuchprovlslmumrthiapemdtahailbe I DING
sensed reenkea.
W F3 CONSTRUCTION LENDING AGENCY SEISMIC FEE '
d L I hereby affirm that there is a construction lending agency for the perform- TOTAL: ELECTRIC FEE O-p0
M z anaof the work for which this permit is bated(Sec.3097,Civ.C.) PLUMBING FEE
Q O Lender's Name
LLr lenders Addreaa QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
Iced(ythatlhavemadthtsappllatbnandtatethattheaboveinfom tion
0 W
Q. Is correct.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
W relating to building consmitbn,and harebyauthorlae representatives of ALTi]t OR ADD7U MECH.
H Z city to enter a Pon the above-mentioned property for Wpetion purposes.
(We)agree to save,Indemnify an d lump harMess the City of Cupertino Date Receipt#
V a gainstlbbilitka.Iudgmx sand expenses which may lnenywayaccme AIR HANDLING UNIT(DO 10,"CFM) SUBTOTAL:
against dCity nco enaof hegrammilefthl perms CONSTRUCTION TAX
AIR HANDLING UNIT(OVER 10,1100CEN)
Sign
pp llc ll ntrador Date IDTIAUS'I HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAMRDOUS MATERIALS DISCLOSURE
Will the pplicant orfutme building occupant store or handle haxadous HEATINGUNITHO100,000BTU) Date Rccel t#
materbl as defined by the Cupetlno Murdtlpil Code,Chapter 9.17,and the
Hnith and Safety Cod,Section 75537(.)7 HEATING UNIT(OVER 100,000 BM TOTAL:
❑ Yes ,LvNo
Will the applicant or Future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous au mntaMvnts as defined bytM Bay Area Air
Quality Management District? BORER-COMP OHPOR 100,0(D BTU)
Yaso
hzvaread the bazarous materials requirements under Chapter 6.95 of BOILER-COMP(OVER100,000 BTU)
the California I Iealth&Safety Code,Sections 75505,75533 and 75534. I
understand that if the building does not mrrcritly haveatenantthatitismy NEWRESIDFNTIALMECH. SQ.Fi.
mip nsIlity noi
sily
ccvP to tPerc ulrcmenin which must be met ^G�
prior ob nu = t=pan . I 0
Own r rauth `/ [).to ISSUIiD BY �/CC
TOTAL:
OFFICE COPY