22310 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pm'ert Identification - PERMITNO.
BuOding Address: YID �Olq 22310
Franc: lh
era1 Nelson -7S')-1qFD CITY OF CUPERTINO-BUILDINGDIVISION �y
no-actor'c Na Lk.Na: APPLICATION /PERMIT
'h $ BUILDINGELECTRICALPLUMSINGMECHAMCAL CATEGORY CONTROL N
• Archltm Englrieer. Lk.No:
QTY ELECFRICPERMIT FEE BUILDING PERMIT INFO
Add..
PFRMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that l am licensed under provisions of Chapier9(commenc APPLIANCFSRESIDEMTAL JOB DISC ON
Ingwlth51.NOto.afd died.
afthe Busliueeand Pro(esslonsCode,and my
]lanae k in full fora and viMo PANELS
Lianss Clam Lk:p
Dale Contractor UP TO 200AMPS
ARCHITECTS DECLARATION 201.10DOAMI'S
0 C20 I understand my plans shall W used u public records. OVERIODOAMPS SQ.Fr.FLOOR AREA E/SQ.FT.
(1 Licensed Prvfeeatonal SIGNSELECTRICAL L E D
«< FkRu OWNER-BUILDER DECLARATION SPECIAL CIl2CNT/MISC
IN
7� owing r affirm that T am 31.5,Bxempt fro Business
a d Prnfictor'e License law for the P�1 T E A
oo
following reason.(6ectlOa 7Bi1.5,Huslness and IProfeakns Code:Any ctry or
O Z H TEMP.MEFFR OR POLE INST.
F� anytykh dortoiapera=t a orequi theapU=tforoWhper ttopair � ,
q any a sped stdorrolbhat he gaLw req-pursuant
to the provisions
of t e OWER DEVICES
3 file a signed statement that he lc licensed9(wra encing with
ISe proWloco f the
Ow Mon 3 ofthe UsinesandProapter9(rom)orthat with xemptthersfction 7000)of Divi- SWIMMING IA70L ELECTRIC
alon3ofthe Busineasand Pm(esskru Code)arthat hek exempt thercfromand VALUATION
yd g the basis for the alleged exemption. Any violation of Section 7031.5 by any
OUTLETS-SWITCHES-FIXTURES<5 applicant foraNrMno m
t subjects the applicant to a civil penalty of norethan
w live hundred dollars(5.500).
NEW RESIDENTIAL ELECTR
�n ❑Inas ownerofoche work,he pro",and
d he rurmmenwlihwaga as Thema for �'FT' STORIES TYI'ECONSTRUC770N
roto 5n
compensation,Business sworkandkxgCde: kTrot Wended orofferedfor
O sale(Sec appy to an ow andf proNny Code:The Cds or ontractor's Limrshersox Law
$
does nor apply toanowmrofthroug hisomwho emplolmprovnthertrortand
uch OCC.CROUP RES TWITS
whodoementsa nor
Naowne.If,however,
er,thaprovidedrthatsuch
Improvementsarenot Intended earofcdforeak.ILhoweveg deer ilI have TOTAL;
improvement bwld wlthinoneyearolcamplellon,.heowner-bulklerwlll have
tF,LIfurden of proving that he did not build or Improve for purpose ofsa)e.). QTY, PLUMBING PERMIT FEE FLOODZONE APN
Lf L as owner of the property,am exeludively contracting with Bcenaed pp OT ISSUANCE "l
CD
contractors to construct the project(Sec.70ty Business and Professions Code: it
4
The Contractor's License law does not apply to an owner of property who ALTER-DRAM&VEN7-WATER(EA)
Wilds or Improved thereon,and who contracts for such p(ojecn with a
op!Q, ec dor(s)licnsed pursuant to the Contrcctor's License Law. BACK FLOW PROTEC7.DEVICE FEE SUMMARY
LJ I am exempt under SB k P C for this rcw
an
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N
Owner Date RECEIPT M
WORKMAN COMPENSATION DECLARATION 6 FIXTURES.PER TRAP SCHOOL TAX Y N
QI hereby affirm the.I have o certificate of consent d self-Insure,ora RECEIPT M
3500,LabC.Worken'Camperuatlan lneurana ora artifled copy thereof(Sec. GAS EA.SYSTEM.1 MCA OUTLETS PARK FEE Y N
3800,Lab C.)
Polity p RECEIPT N—
Policy
�nY CAS EA.SYSFEM-0VERd(EA) BUILDING DI VISION FF.ES
ertified copy ls hereby(uMshed. GRFASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
Certified copy b filed with the tlty Irupectlon division.
CERTIFICATE OF EXEM PTION FROM WORKER S' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANITARY-STORM EA.2DDFT. Date Recel I#
(Thbeectian need ns.becompleted If/he perMt ls forone hundred dollars
($1I0)arfess.) WATER HEATiRW/VENT/ELECTR 'Z.,OU ENERGY FEE Y N
Ill note m in thepersiperformance any
man oris for as
to beds a subjrmitect
c issued,
I soapnotemploy any Laws f any nunnerat as to become vrb)ett io the WATERSYSTEM/TREATING
Workers'Compewrlon laws of California.Date PAID
O Z AppliNOTICE
NEW RESIDENTIAL PLMB,_SQFF. Date Recei t#
Z O NOTICEca APPLICANT.If,ager makingthis
Compensation
Eemptioofthe Lyou
H Code, ou=stme urthwitect co Workers'suchp visioprovhlomrmit s Lobar TOTAL:
W N Code,d..kerforthwith comply with euchprovlskru arthb permit shall be BU
> deemed revoked.
W p co1vSTRUCTION LENDING AGENCY SEISMIC FEE
CL IherebyaBirm thatiherekaou tmctlan lending agency for the perform `s� ELECTRIC FEE
7 Z ante of the workfor which this permit b tseud(Sec.309 a,Civ.C.) TOTAL:
(.) 2 Ie^de/•Name PLUMBING FEE
LL F Lender's Address QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OW 1certilythet l haveread this application and patethatthe above information
1 L+mrrect. to comply with aft city and county ordlnanm and gate laws PERMIT ISSUANCE FEES PAID:
} W relx.in o Wildi grorutructioM andhereb authorlu represents lveto f this -
1— Z city! enter- iheabov ntioned erty forinsp Nap sed. ALTER OR AUDIO MECH, Date Reeei t#
to Live, ify an ke p harmle City Cupertino
ggran
gains drCiry Ind co&a to nlnswYin Ywayamme AIR HANDLING UNIT(TO 10,ODOCFM) SUBTOTAL:
a
._. g s ,parm
NR HANDLING UNIT(OVER)0,000CFM) CONSTRUCTION TAX.
Signa reof Appll t ..radar Date EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
RDOUS MATERIALS DISCLOSURE
Willtheappll tor(ulvrebuilding occupant store or handle hazardous HEATING UNIT(TO 100,000 BN) Date RCCeI t#
materia)as defined by the Cupertino Municipal Code,Chapter 9.17,and the
Healthand Safety Cod a Sect ton 25532(a)T HEATING UNIT(OVER 100,000 RTI!) TOTAL:• '
my. No
Will the applicant orfutamWilding occupant use equipment or devices VENTILATION FAN 6INCLE RFSID) ISSUANJ@ttb R91'h'
which emit hazardous air conks nurunts as defined by the Bay Area Air ��'T�L`N
Quality Management District? BOILER-COMP PHP OR 100,IX0 BIT!)
941931
Yrs ❑No JUN II N
eve read the hazardous materials requimmenta under Chapter 6.95 of BOILER-COMP(OVER 100,000 BN) d��
the Califomla health A Safety Code,Sect Ions 25505,25533 and 75536.I
understa cad that if the building does not currently have a tenant,that It is my NEW RESIDENTIAL MECL SQTr.. a...
responsibility to notify the occupant of the uqulrements which must be met r
01 cup
prior to issuance of a Certificate of Occupancy.
Owner or authorized agent Date ISSUED BY:
TOTAL:
0FFICE COPY