22454 (2) APPLICANT TO FILL IN INFORMATION WITHIN REDLINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Building Address: i Z Z 4 5
p ► voo I�we t l
nerd one: A
?G5-3?/6 CITY OFCUPERTINO•BUILDING DIVISION
Con Name; LIc.NO: APPLICATION /PERMIT
IL KN 1 e/I % BUILDING-ELFJCTWCALPLIIMBINC-MECHANICAL CATEGORY CONTROL N
Architect/Eng.neee Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Add. PERMITISSUANCE ❑ 1:1LICENSED CONTRACTOR'S DECLARATION
Thereby fit.that l am licensed under Frontal....f Chapter9(commm APPLIANCMRESIDENTIAL ]OB DESCRIPTION
Ingwlth SeMon7000)of DiAMon3ofthe Budnemand Pmfe onsCode,andnry
license bIn I.ss to and .#ffect'__,� PANELSLk,xr
D.tr_ Clan Cm Y x
Date ContractorUP TO 200AH5
ARCHITECTS DECLARATION - 301-1000 AMPS
X zI understand my plana shall be useas public blic records. OVER 1000 AMPS SQ.ET.FLOOR AREA f/SQ.Fr.
k 19 LI¢ PmfPmfemi..I SIGNSELECTWCAL 1 6
LED I #
<F.6 OWNER-BUILDER DECLARATION T E R
z
m SPECIAL CIRC[RT/MISC
�j Iwmitthe afnrmthatlama%em from a Conifcaniu,Iced Law L}+✓�
ZO "..l following reason.(Stolon 7Rf1S,Buslneve and Profenbvn Cede:Any tlty or TpA{p MEfIX OR POLE INST. 1
PE' countywhich requbes a permit to construct,alter,Improve,demolish,or repair any S
any structure prior to Its issuance,also requies the applicant for such permit to
(5 O file a signed statement that he b licensed pursuant to the provblons of the POWER DEVICES `,Kw]%l� /
f6il Contractor'sLicense Law(Chapter 9(commendng with Section 7000)of Divi- SWIMMING POOL ELECTRIC VALUATION
�5 slon3ofthe Business and Prom
fe .Oru Code)orthat heft emmpttherefromand
the Web for the alleged exemption. Any violation of Section 7031.5 by any
« OUTLEISSWITCI-ISFLYEURFS
applicant fora permit aubjthe applicant to a civil penalty of not more thapermiteas
five hundred dollars(5500).
NEW RESIDENTIAL ELECTR
7�n ❑I,as owner of the Property,or my employees with wages as their sole �'ET• STORIES TYPECONSTRUCTION
mmpeneait wRldo the work andthestmortre b nm Intended or offered for
O mle(Sec.7064,8usirlen and Professions Code:The Contradots License Law
�,I$$ does nm.pply to an owner olpropeny who Wilds orlmprovesthercon,and OCC.GROIIP RES.UNITS
0.0. who docesuchworkhlmseUorthraugh his own employen,provided that such
bnprovements are not Intended oroffered forme.I!,however,the W.Idingor TOTAL:
Improvementissold wlth.naneyearofcampldlon theowner-W Bderwill have
tlR-Ifurden of proving that he did not Wild or Improve for purpose olsale.). QTy. PLUMBING PERMIT FEE gpODZDNE APN
Lj 1,as owncr'.f the property,am exclusively rontracting.wl ...¢need
contractors to rontrod the projed(Sec.7064,Business and Prolenlom Code: PERMIT ISSUANCE
1he Contractor's License Law don not apply to as owner of property who ALTER-DRAW 4 VEM-WATER(FA)
bunds or improves thereon,and who contrails for such prajn s with a
ogntIactor(s)Bernrd pursuant to the Contractor's License Law. BACK ITDW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sea B k P C for this reason
OUTSIDE F7LES
DRAINS FLOOR ROOF,ARCA,GOND. SANITARY Y_ N_
Owner Date RECEIPT
WORKMAN COMPENSATION DECLARATION
01 hereby affirm that I have a certWcaFIX'IVRF_S PER TRAP SCHOOL TAX Y
te o!consent to self-Insure,or _ N
NN
certificate o!W.,kers'CompcmatlonImran¢ora¢rdf ed copy thereof(Sec. RECEIPT
3800,Late GAS EA.SYSTEM-1 WCAOUTLETS PARK FEE Y_ N_
Policy It 1 6700/ -9 Z RECEIVE#
T— GAS.EA.SYSTEM-OVER 4(FA)
Com any S�atxl 'I BUILDING DIVISION FEES
CCenified copy's hereby city GREASE/INDUSIR,WASTE INTERCEPTOR PLANCHECKFEE
ff eZ fied copy b nod with the dry inspection division.
CERTIFICATE OF EKEM PTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA 20081• Date Recti t#
Rhsedlon need not be compldad I(the permit b fororn hundred dollars
(g10(fierorlen.) WATER HFATERW/VENT/Fi erTR ENERGY FEE Y N
I¢nifythat Nthe perfammn¢o(thew¢klorwNch this permit is Weed,
I shall not employ any person In any manner so n to become subkd to the WATER SYSIIIH/TREATIN'G
Worla Compensation laws of California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB, JQFr. Date Remi t#
Z O NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you
should beacons subject to the Workers Compensation provision ofthe Labor TOTAL:
N Code,you most forthwith comply with such provision orthb pemdt shall be
W > deemed revoked. BUILDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE .6Lao
a Tberebyaffirm lhattherebamvtrudlon lending agency for the perform- ELECTRIC FEE
U�.Z ance of the workfor which this permit is imued(Sec.3097,Civ.Q TOTAL:
O Lender's Name PLUMBING FEE
LL I— Lender's Address QTY. MECHANICAL PERMIT FEE bmMECHANICAL FEE
O W ¢
Inlfythatl have readthb applicetionand YatethAtheabove Information
G ncct.I agreetocomplywith al.dtyand muntyurd.nanmand nate laws PERMIT ISSUANCE FEES PAID:
> N relating tobu.lding ronatmdlon,and hereby autherlae representatives of this
1- Z city to enter upon the above-mentioned property for inspection purposes, ALTERORADDTOMBCH. Date ReCel t#
_ (We)agree to save,Indemnify an d keep harmless the City of Cupertino
ag.1tliab tics,ydgmenis,mnsandexpensnwhkhmayNa ywayac a AIR HANDLING UNIT(TO 10,000CFM)
ag.lret til Immmsequenaeofthe rating oft pent SUBTOTAL:
' AIRHANDLING UNIT(OVER IQOWCFM) CONSTRUCTION TAX
Sigm( e p a t/Cooyyf� db ate EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
., R S MATERIALS DISCLOSURE ,
Will the appB¢nt or futlHlre Wlldingaccupantsioreorhandleh.,d.us HEATING UNIT(TO 100,000 BTU) Date el)t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the - PA
Health and Safety Code Section 25532(x)7 HEATING UNIT(OVER 100,000 BTU) - TOT l
❑Ym 1t�-,1 N.
WlLoat xpplleousarcomaWilding o¢define use by tequipment he Bay Area devices VFNITLATION FAN(SINGLE RESID) �6[SS E
whkheMthageovet attrict? nnh as defined by the Bay Area Air
Illy Mawgement DbMd7 BOLI-ER-COMP OFfI'OR 100,00110111)
uL��Yn ❑No /sussunY�{M
Ihavcread he Health
Safety
mode, etioW¢menb5533 and 23511.
of BOILER-COMP(OVER 100,000 BTU) Tisa 1+ys-
the California Health b Safety Code,Sections 25505,25533 a t and 25536.I
understandthatRthe building para note currentlyhavetenant that it bony NEW RESIDENTIAL MECtI. SQ.FT.
,nor to isaaa cerad itythe iate of cctherequlremems which must be rsiet
prior to Issuanca of a Certificate of Occupancy.
Owner or authodaed agent Date ISSUED
TOTAL:
OFFICE COPY