22863 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES- USE BALL POINT PEN ONLY
fluildirot Proled Identification PERMIT NO.
Building Address: 22863
I -7 a 1 i fl
nen ane. APPLICAT ON SUBMITTAL DATE
fit A, _73a-7395- CITY OF CUPERTINO-BUILDING DIVISION j\
C no.dor.N : I u.N.: APPLICATION / PERMIT
BUILDING-ELECTRICAL-MUMBING-MFCHANICAL CATEGORY CONTROL#
Archl ed/Engtnrer. Llc.No:
^
QTY ELECTRIC PERMIT FEE
BUILDING PERMIT INFO
Addr jAofsL :AAI 1 L PERMITISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
t hereby affirm that l am licensed under provislonso(Chapter 9(commen APPLIANCES-RESIDENTIAL JOB DESCRIPTION
IngwithSedion7000)of DlWdon3ofthe Butlauand PmfefaimsCode,and m
Ilceae is In(u0 finen dd(ect. PANELS
License Clam G 3(�, Lir.#�
Date 10- Conrado
ARCHITECT DECLARATION 201-1000 AMPS
p�p�uumz I understand my plana shag be used u public records. OVERIOOOAMPS .5Q. •Fr. OR AREA E/SQ.Fr.
00
E U Licensed Professional SICNSELECTRICAL 1\1— ED IN
Q OWNER-BUILDER DECLARATION
1'n SPECIALCIiCUIT/M19C
E„ owing asOrm that l.....pt31.5,B fromass a d Profiresu License Law y for city or
11
'z
following mason.(SMion 70f15,Business and I'm(esbne Code:My tlty or III J 1
7FMP.MEfLR OR POLE INSf. `a.. ail
� UTEF
rountywhlch mrylresa permi[tomretrud,alter,Improve,dennllsh,orrepalr moi' of !L(r•
5
anystmclure priorto itslssuance,also requireslhe applcantforsuch permit to POWER DEVICES
file a signed statement that he is licensed pursuant to the provisions of the E
3µ i Contradors License Law(Chapter 9(mmmencing with Section 7000)of Divi- SWIMMING POOL ELECTRIC
X05 slon3 ofthe Business and Pro(esalores Code)orthat he is VALUATION exempttherefromand
the basis for the alleged exemption. Any violation of Stolon 70315 by any OUTLET'59WTTCHESd1XIURES
appReant for a permit subjeds the applicant to a civil penalty of out more than —�
Eve hundred dollars($500).
�n ❑I,a owner of the ro NEW RESIDENTIAL ELECTR SQXT. STORIES TYPE CONSTRUCTION
p perry,or u employees with wages a there dale
C sale
ampenatl4k Business
and Pr andthesC de:Th Contot ended or imnst,Law
5 d for
p doas nor
pplyt an
andProfessions
property who builds
or Improves does Lenon Law
{{3g whodo ,such oak owner ofpropertynem oyeas,povidedthatsu h CCCGROUP RES UNITS
E wproveentsam khlmsended orwgh Neowne.If,hoger,thedthatmch
improveend b arenot Intended etudco morale,ILhowever, Uder ill have TOTAL:
Improvement lssold withinoneycarofcompldion,theowner-bulderwlll have
tl n�¢uden of proving that be did her,build or Improve for purpose ofule.). QTY, PLUMBING PERMIT FEE
LI L as owner of the properly,am exclusively mntrading with licensed FLOOD ZONE APN
mnlradors tocorisWd the pmjed(Sec.70M,Busineaand ProfessionsCode: PERMIT ISSUANCE
The Contractor'License Law don not apply to an owner of property who ALTER-DRAIN k VENT-WATER(EA)
builds or Improves tberam, and who contracts for such p(o)eds with a FEE SUMMARY
C tt(ader(d)licensed pursuant to the Cmumcb .License Law. BACK FLOW PROTECT.DEVICE
LII am exempt under Sea B 4 P C for this mason
OUTSIDE rrQ
DRAINS R FLOORCOF,AREA,CONE. SANITARY Y N
Owner Doe RECEIPT#
WORKMAN COMPENSATION DECLARATION FIXTURES N_
m PER TRAP SCHOOL TAX Y_
pI hereby affirthat 1 have a certificate of consent to self-Insure,or a RECEIPT#
certificate o(Worken'Compemation Insurance Ora certified copy theueof(Sec.
3800,Lab CCAS EA.SYSTEM-1 INCA OUTLETS PARKFEE Y N PolicyRECEIPTp
p CAS EA.SYSTEM-0VER 4(EA)
Com any_ y/ - BUILDIDINGGDE DI VISION FEES
9Certin copy le filed
edwby th the he . GREASE/INDUSIRL WASTE WTFRCEPTOR PLANCHECK FEE
Certified ropy b filed with the dry inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREA'SETRAP PAID
COMPENSATION INSURANCE SEWER-gpNDMY-STORM EA.200FR. Date Recei t#
(This,edlon need not be completed if the permit 0 for one hundred dollars
(SIOM)mIda3 WATER HEATER W/VOM'/F3.ECIR ENERGY FEE Y N
I certify that In the performance of the work for which this permit is Issued,
I,hal not employ any person In any manner an an to become subject to the WATER SYSTEM/TREATING
WmInars'ConhsmsaOon Lawsof California.Don_ PAID
O Z Applicant NEW RESIDENTIAL PCMB. SQ.FT. Date Revel t#
.Z O NOTICE TO APPLICANT.If,after making this Certllcate of Exemption,You
Fshould become subjcet to the Warkars'Compeaation provisions of the Labor TOTAL:
N Code,you=at forthwith comply with such provisions or this permit shall be UI
W j deemed revoked. -
LDING FEE
CONSTRUCTION LENDING AGENCY SEISMIC FEE
O. C Ihercbya(Orm that there is construction lending agency for the pedormry
0 Z once oftha wmafer wMeh thin permit b Luteol Sec.3097,Civ.C.) TOTAL: ELECTRIC FEE
02 LanderaN.me PLUMBING FEE
LL lenders Address. QTY. MECHANICAL PERMIT MECHANICAL FEE
OW Icertifythat l have read chinappilcaliOnandemnathattheab.,,informaOOn
IL Iscorred.l agree to complywith all city and county ordinances and state laws PERMIT ISSUANCE FEE$PA1D:
} W relatingtobuilding construction,and herebyaulhorize representadvesoflhls
Z city to enter upon the abo.enttioad Property for inspection purposes. ALTHiORADDTOMECH. Date Receipt#
(We)agree to ave,indemnify an d keep harmless the City of Cupertino
V against RablWles,judgments,coaband expemn which may in anywayacdu, AIR HANDLING INR CrO 10,ODOCFM) SUBTOTAL:
agaiatuld0ty daequencedthe granting of this permit.
�" ili�# M AIR HANDLINGUNR OVERIO,000CFM) CONSTRUCTION TAX
sig r pp ca t/ ontXraddorrr Dale f EXHAUSTHOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfutum building coupantatore or handle harardous HEATING UNIT(F0100,000 BTU) Date ReCel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Cade Section 25532001 HEATING UNIT(OVER 100,000 BTU) TOTAL:
Fly. �j No
Will the applicant or future building occupant use equipment or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hamnious ab contaminant,as defined by the Bay Area Air
ality Management District? )TOILER-COMP OFR'OR 100,000 BTU)
Ye, II�1I No
ve read thehazardous materialsrepulrerrenb under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k SafetyCode,Sections 25505,25533 and 25534.1
understand that tithe building don re
not currently have atenanL b
that it N<EW RE9DFNHAL MECH. SOFT'
responsibility to notify the occupant of the requirements which must be met
prior to IssuanceOf a Certificate of Occupanry.
Owner m aulhm1xad agent Data
TOTAL: ISSUED BY:
OFFICE COPY