23222 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PFRMITN23222
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Building Address: 3 Z Z Z
c, z (�l2'� b-�L wck
Phone: A
La a� CITY OFNPERTINO-BUILDING DIVISION
contrado aName: « BAPPLICATION / PERMIT
CATEGORY CONTROL
Arc itnct/Engineer. (/aMDINGELFCTRICALr'LUMBINC-MDCHANICAL
Ic.
No:
QTY ELECTRICPER FEE BUILDING PERMIT INFO
BLDG EL�l PLUMB MEL I
Address: PERMITISSUANCE �) O ❑
LICENSED EDCONTRACTOR'S..daDECLARATION LT}
I heh Sacti n70that lam Bcen3ofthe usims Wonsel Cssims 9(e,andm APPLIANCES D L JOB DFSCRRrfION
ingwe 1Section force afdall on3o(the Buslnessand Profcaions Code,and my ///^^^
license K1.lass force and all C �� �7^
Date
LIC( J �A,
Date � � ' Contractor
ARCHITECT DECLARATION iIAMPS
15
2 (understand my piston hall be da+publlc records �. ARP�I� S/SQ.Ff.
q� O tl
ty Fj Llrend Professional 9 NS ELECTRICAL/fiTER N OWNER-BUILDER DECLARATION SPF.CIALCRRCUIT/MLSC P
i.., Ihcrebyarmthatlamexemprom
tfthe Cont.dors Llceree law(mthe �V T
7 following reason.fSection 7041.5,Business and Professions Code:Any city or
TEMP.METER OR POLE(NST.
ntywhichreUequper.Nttomnatrun,alter,4npmve,dennlbh,orrepalr FR 3 1
q e couanystructure Inform its becance,alm requlrestheapplicant for such permit to POWER DEVICES DATE
EE file a signed statement that he Is Ilrenaed pursuant to the pmvfvloru of the
Contractors License Law(Chapter 9(commencing with Section 7000)of Divi- SWIlIMING TOOL ELECTRIC VALUA O
O von3olthe Burin®nand ProfeaTOre Codc)orthat heisamm ehere/comand �d
P1 y2 the basis for the alleged exemption. Any violation of Sects nt 70211.5 by any OUTLETSSW(TCHFSFIXTUR65 � O —,
0< applicant tons permit subjects the applicant to a civil penalty of not more[ban
y n five hundred della.(MM. NEWRFSIDENTIALELECTitSQ.FT. STORIES TYPECON5TRUCTION
? I,as owner of[be property,or my employees with wage as their sole
Scompensation,will clothe work andthestructure Is not intended or offered for D sale(Sec.7044,Business and Profesiora Cade:The Cmt.dors License Law
does not apply to an owner of property who Wilds or Improves thereon,and OCC.GROUP RES,UNITS
F�^ who does such work himself orthrough his own employees,provided that such
improvements are not intended or offered for sale.If,however,the building or T
Improvement issold withinoneyearofcomplebn,theowner-buRderwiil Tuve
it( rdenofprovingthathedld not build or improve for purpose of sale.). QTY. PLUMBING PERMIT IEE FLOODZONE APN
1:4 as owner of the property,am exclusively contracting with Ilcensed PERMIT ISSUANCE
contirders to construct the project(Sec.7044,Bushman and Professions Cade:
The Contraaor's Liconse Law does not apply to an owner of property who ALTER DRAIN k VENT-WATER(EA)
Wilda or improves thereon, and who contrads for such p(oje with a FEE SUMMARY
'gWdor(s)Bcend pursuant to the Contractor's License Law, BACK FLOW PROTECT.DEVICE
I I1 am exempt under Sec. B k P C for this reason
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY RECEIN
i� WOR KMAN COMPENSATION DECLARATION p7XT1JRES PER TRAP SCHOOLTAX Y_ N_
❑I hereby affirm that 1 have a certificate of consent to sell-Insure,or a RECEIPT I
certificateofWorkers'Compensationlrou.nm ma cortlfhd copythereof(Sec. GAS PA.SYSTEM-1 INCA OUTLETS PARK FEF Y N
3800,Tab CJ IRECEIPT M
Paltry I GAS EA.SY5lTM-OVER 4(EA)
Com any BUILDING DIVISION FEES
�CcrtiOcd copy is hereby furnished. PLANCHECK FEE
IQCertltied copy is filed With the city city inspection division. GREASE/INDUSIRL WASTE INTERCEPTOR
'(yam CERTIFICATE OF EXEMPFION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 2pF7 Date Recti t#
(rhlssectlon need not W completed if the permit is forme hundred dollars
(SIM)or lea.) WATER HEATER W/VENT/ELECTR ENERGY FEE Y_ N_
I certJythat in the performance of the work for which this permit is laced,
1 shall not employ any person In any manner so as to become subject to the WATER SYSTEM/TREATINK;
Workers Compensation Laws of California. Date PAID
OZ Applicant Date Rcmi t#
Z NOTICE TO APPLICANT:If,a her ma king this Certificate Of Exemption,you NEW RESIDENTIAL PLMIL SQ}T.
O should become subject to the Workers'Compensation pmvlsiom of the Labor TOTAL:
CCW Cade,you must forthwith comply With such provers or this permit shall be BUILDING EE
2 j deemed revoked.
W — CONSTRUCTION LENDING AGENCY SEISMIC FEE
CL Ihereby affirm that there is a commuctdon lending agency for the perform- TOTAL: ELECTRIC FEE
Z ante
fthe work for which this permit is lacmd(Sec.3119'1,Civ.CJ
00
I<nder'sName PLUMBING FEE
LL I— Lender.Addrea, Q'Iv. MECHANICAL PERMIT FEE MECHANICAL FEE
O Icertlfy that l have readthbappldcationani statethat theabove information
O
1 Iscomed.I agree to comply with all city and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
). relating tobullding construction,and hereby authorize representatives of this
city to enter upon the above-mentioned property for lnapeation purposes. ALTERORADDTOMECH.
Date Receipt#
Z
_ (We)ages to ave,Indemnity an d keep harmiea the City of Cupertino AIR HANDLING UNIT(TO 10,003 CFM)
against liabilities,Judgments,"sand expenses which may in anyway accrue SUBTOTAL:
agaireta d dry Inc ceof the gan'ng of this permit
en AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
atum o7AftPcanfaCAtrRtor EXHAIISTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bu0ding occupant store or handle hazardous HFATING UNIT(TO I(1%0D0 BTU) Date Recef t#
material as defined by the Cupertino Municipal Code,Chapter 9.1 2,and the
I With and Safety Colrer—Section 25532037 HEATING UNIT(OVER 100,000 BTU) TOTAL
0 Ye u No
Willthe applicant orfuturebuilding occupant use equipment ordeviare VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
Which emit hazurdousair conlamlnantsas defined by the Bay Area Air
Quality Management District? BOILER-COMP OHPOR 100,000 BTU) , 0
Yrs No
have read the bazar our materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health&Safety Code,Sections 25505,25533 and 25534. (
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. Cir OSI
responsibility to notify the oemps in of the requirements which must be met /-
prl to same Of Cc ificateof0cvup cy. rU `Ur't/y
�i
Owner or auutthhorl�d agentTOTAL:
Dale ISSURU BY:
OFFICE COPY