22646 (2) AYYL-IUAN 1 10 FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY '
Building project identification PEILMTNO.
Building Address; -
22646 wnera /V T �O< -
�.y�. me - A
- ��%Ti CITY OF CUPERTINO-BUILDING DIVISION
on
A.eitimse Le'N°' APPLICATION /PERMIT
.. -mmmct/Engineer: BUILDINGELEOTRICALPLUMBINGMECH LAICAL CATEGORY CONTIIOLa
Lk,NO:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address. O /I i
LPERhBTI55UANCE
R'SS DEC ❑ ❑ -
LICENSED CONTRACTODECLARATION
IhthSy on7Offirm that lsm,1.3ofunder pemand of Chapte C6de,and my APPLIANCES-RESIDENTIAL JOB Ll S 'HON
If...I I-Full f%W.!Dlvisian3o(the BuWineeand Pro(naloneCede,and my -
Li.. I-I-fuBfeilplend k,# <W z� PANELS
Li
License Clam S1 Llc p_-J�/>'
Date Contractor ITS -
ARCHITECI S DECLARATION 201-1000 AMPS
re0 0 I understand my plana shall be used an public records. OVER 1000 AMTS SQ�Fr.FLOOR AREA $/SQ.FT.
SIGNSELECTRICAL<�6OWNER-BUILDER DECLARATION SPECIALCIRCUIT/MISCR L_ E D 1 N
Z' 4 ihereowing yasormthaton 7LIH ,Bug.ethe Contractor's Lianas Law finehe rt n P U T R
ZO F following reason.(Semon 7031.5,Business and Isrofeseicns Code:Any city or 6\V/'
p,� county requlresa permit construct,alter,improve,demolish,or repair TFMP.METEROR POLE INST.
Q any structure prior to its issuance,also requires the applicant for such permit to
U file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
30y- � mme
Contractor's License Ls. with Section 7000)of Divi- ATE G
qEli S Mon3 ofthe Busumosand ProfessimuCode)orthat he ls exempt therefromand SWIMMING POOL ELECTRIC VALUAT ON
C thebash for theallegedeOctnth a a Anyviolationtola con of Section70115by reany OUTLETSSWITCHFSFIKTURES0�`v+
appgcantfor apermit aubjectstheappgcant too civil penalty.(net morethan it
fNd� five hundred dollars Woo). NEW RESIDENTIAL ELECTR
�n ❑T,as owner of the property,or my employees with wages as their sole SQd'T• 'STORKS TYPE CONSTRUCTION
compensation,wWdothewml a dth,mmu rehnmintended or offered far
O sale(Sec 70K Business and Profeasimes Code:The Contractors Mcere,Law
3$ does not apply to an owner of property who Wilds or Improves thereon,and
whadoeeauchworkhlmaelf or through hr'sownemployee,provided that suchOCGGROUP RES.UrIS
Improvements are not intended oroffered foraale.If,howevegthebulldingm TOTAL:
Improvement issold withinoneyearofcompletfon,the owner-builderwlll have
t4tIsirden of proving that he did not Wild or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE
u L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
connectem to construct the project(Sec.7044,Buelnen and Pro(emlow Code; PERMIT ISSUANCE
The Cantmctor9 License Lw don not apply to an owner of property who "
Wilde cur Improves thereon, and who contracts fm such ptojects with a ALM-DRAIN&VENT-WATER(EN
ogB[[aem(9)Hanged pursuant to the Contractors License Law. FEE SUMMARY
LJ I am exempt under Sec .B&P C for this recon BACK FLOW PROTECT,DEVICE OUTS[np FEES
• Owner Date DRAINS FLOOR ROOF,AREA,(AND. SANITARY Y_ N
WORKMAN COMPENSATION DECLARATION RECEIET X
QI hereby affirm that I have a nrtiBcate of consent to,elf-Insure,m a FIXTURES PER TRAP SCHOOL TAX Y N
ttrtiflcate of Workers'Compensation Insurance ora certified'copy thereof(Sec, RECEE'I k
3800,Lab CJ GAS EA.SYSTEM-1 INCA QUTLEIR PARK FEE - Y N
Policy p RECEIPT X .
CoS (E
m any GAEA.SYSTEM-OVER BUILDING DIVISION FEES
�Certlf copylshereby furnished. GREASE/INDUSTRL WASTE INTERCEPTOR - - PLANCHECK FEE
fled copy ls(Red with the tlty Irupection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE
(Thtssectlonneed not becompleted ifthe permit isforonehundred dollars SEWER-SANITARY-STORM EA•200FT. Date Recei t#
(Slop)orleae.) - ENERGY FEE Y N
Ill Our thatemploy
in oy an Person in an tovemer so as to become
Issued, WATER HEATER W/VENT/F]-EGTA
I Whale nm empien any Laws of any manner so n to become subject to the
Worlicant mpeneation Laws of California.Date WATER SYSTEM/TREATING
O Z NOTICE
PAID
1Z' O NOTICE TO PLICANT
objettothe orkenekingthheation cateof Ex,ofthenI you NEVJ RESIDENTIAL ELMS. SQjrr. Dates Recel t#
should become subject m the Workers'Compe�uatlon provlsloru.(the Labor
(/9 Code,you moat forthwith comply with such provisions or this permit shall be TOTAL:
LU > deemed revoked. BUILDING FEE co
a p CONSTRUCTION LENDING AGENCY SEISMIC FEE
Z
= I hereby affirmthat there is a construction lending agency far the perform.
O ance ofthe work forwhich this permit is lssued(Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
U _ Landers Name PLUMBING FEE
U. Lename Andres, QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W Icertifythatl have read thisappHotionand state thattheaboveinfomution
a broned.I agrmto complywith all dtyand iountyonilnanons and state laws PERMLFISSUANCEFEE$PAID:
( relating to building commuctlnn,and hereby authorize representative ofthla
1— Z city to enter upon the abovcmenticned property for Inspection purpose,, ALTER OR ADD TO MECH.
(We)agree to save,indemnify an d keep harmless the City of Cupertino .Date Receipt#
agalmt lithe,' dgmenh sat xpenseW ichmayinanywayamue AIRHANDLING UNIf(TO]O,ODOCFM) SUBTOTAL•
a al dCl na. rare grantin
AIRHANDIANG 11Nrr(OVERIDODocFM) - CONSTRUCTION TAX
Signature°!Applica, tactor a EXHAUSTHOOD(W/DUC'O CONSTRUCTION TAX PAID:
HAIRYy OUSMATERIALS DI SCLO URE
Willtheapplie"M future building occupant store or handle hazardous HEATING UNIT(TO 100,000 BTU
• material as defined by the Cupertino Municipal Code,Chapter 9.12,and the ) Date Recei t#
Health and Safety Code Section 25532W7 HEATING UNIT(OVER 100,000 BTU I
❑Yes rN No TOTAL:
Will the applicant or future Wilding ompant use equipment or devices VENTILATION PAN(SINGLE RESID) I$$UA E
which emit hazardous air contamlnznts as defined by the Bay Area Air
AT
Quality Management District? BOILER-COMP OHP OR 100,DM BID)
Yea ❑❑No p
Cali
ave read the hazardou,materlals requirements u Oder Cha Ater 6.95 of BOILER-COMP 100,000 BTU) �I � {p � '( )
the fomla Health&Safety Code,Sections 25505,25533 and 25534.I
understand that lithe the ing doesoccupant note currently have tenant,that It my NEW RESIDENTIAL MECH. SQ.E7. as.,
repo to Issuyto notify Ccrtiocate of0c pa ncyulrerrcnte which must be rret 'Ra'7"M
prior to lssuanre ofa Certifl<ate ofOccvpanry. '
Owner or authorised agent Data -
, TAL: ISSUE
TOD BY:
OFFICE COPY