22965 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT'PEN ONLY
Building Pm nal Identification
Building Address: PERMIT NO.
22965
APPLICATIONSUBMITIAr=A
nerd send: one:
CLC 7 CITY OF CUPERTINO-BUILDING DIVISION
ca d LI°. a APPLICATIONIPERMIT l —`
ArcMtect/Ungloaer. BUILDINGELUCTRICA1uMBING-MUCIiAMCAL CATEGORY CONTROLp
Lic Na
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Addrcas: / '/
PFRh9iISSUANCE ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm tlutlam lkmsed under provisions o(Gapter9(mmmm APPLIANCESRESIDEN'TIAL JOB OUSCRTPDON
Ingwith5ectlon 7000).(DWiYon3ofthe B.Mn.M.nd ProfesslonsCodgand my -
Bunaelelnfyll and died. pANps
License Cla6r LIeY��9��n I
... . IrAICc.OinDate IIII r7
ARCHITECPS DECLARATION 2014 000 AMPS
9z I understand my plana shag be used as public reomda OVER 1000 AMPS SQ.Fr.FLOOR AREA $/SQ.Fr.
0 Licensed Professbral SIGNS ELECTRICAL
< OWNER-HOLDER DECLARATION �x D
gH �a Iherebyaf0rm lOWNE -HOL ER DE LARATI iBLkenae law futhe SPFOIALCIRCUIT/MLSC IR
(oil g realm.(Section 7031-5,Rusbuse and Professions Code:Any city or
i-" countywhkhmgqu a apemdttomr th a,alter,bnptovs,dennlbh,orcepalr SMI.MEM OR POLE INSI. T
fiQganystm=mPeortolblewancgalwrequlmslheapplluntforsuchpemdtta t
fin
n� file a dBI statement that he b licensed pursuant to the provide Of the POWER D��
ER
3 w0 fn Contnd.e.Litmus law(Chapter 9(mmmenclag with Section 7000)of Divi-
elon3o(the Busbs"and Professlaro Code)orthathehexsmptthemfmmand SWIMMING POOL ELECTRIC QA
6 VALUAH N S the basis for the alleged exemption. Any violation of Section 70'31-5 by any 7 '
q applicant for a permit mbjects the applicant to a civil penalty d room ore than OUTLETS-SWITCHES-FIXTURES
fiv hundred dollars($500,
z5t Lj I,as owner of the property,or my employees with wages as their sole NEW RFS[DFNITAL ELECTR SQFT, SrORIFS TYPE CONSMUCHON
Fa compeneatlon,will do the wort{,and the stroctureisnot Intended or offered for
O
-Is(Sec.7NA,Bonuses and Professions Code:The Contractor's License Law
does m-pplytaanownerdpropertywhobuild°orlmpros•nlhe.,o d
aaa who doe°sech work himself orthmugh hlsown employees,provided that such OUC.GROUP RF&LMTS
Improvements am not Intended oroffercd(weak.If however,thebullding u TOTAL:
improvement hsold withinoneyear.fcompldioa,theawner-bullderw111 have
tFA! urdenofpmvingthathedid not build orlmprove foipurposeofsale3. QTY. PLUMBING PERMIT FEE
LLj L as owner of the property,am exclusively contracting with licensed FLOOD ZONE APN
mmnenue to torered the project(Sm.7074,Business and Prdessioro Code: , PERMIT ISSUANCE
The Contndoe,License Lw does not apply to an owner of properly who
build. or Improve.thereon,and who comracis for such pnojecta with a ALTER-DRAIN&VENT-WATER N.N
cgIl(IaMI Ilsesed punumt to the ConmI License Law. FEE SUMMARY
LII am exempt under See. B& P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDE FEES
Owner Date DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
WORKMAN COMPEtlSATION DECLAKATION RECEIPT R
QI hereby storm that I have a certificate of consent to self-insun,or a FIXTTTRE-&PER TRAP SCITOOL TAX Y N
certificate o(Workers'Compewtion Insurance or a cetifled copy thereof(Sec. A RECEneT'N
3800,LebC) 7�p��-- CAS EA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
Pollry p / RECEIPT ef
Com anyow K GAS EA.SVSTEM-OVER 4(EA) BUILDING DIVISION Il?ES
oCertl ed copy b hereby Turnlshed.
oCertlfled copy b filed with the city laspMlon division. GREASE/INDUS'TRL WASTE INTERCEPTOR PLANCHECK FEE
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thbsecionneed net becomplated lithe permit lsfarom hundred dollars SEN'ER-SANITARY-STORM EA.20eFT, Date Recei t#
($IW)w less.)
I certlfythat N the Perforreance.fthework forwhich this permit is lsmed, WATER HEATE3W/VENT/ELECTR ENERGYFEE Y_ N_
Isbell not employ any person In any manner n as to become mbjea to the
O W plica'Compensacbn LewsofCeRfomla.Data W'ATERSYSTTM/TREATING PAID
Applicant
Z 0 NOTTCETO APPLICANT:If,after mak3ngthb CertBluteo(Ezempcon,you NEW RESIDENTIAL PLMB,__SQFr. Date Reeel t#
FN should become subject to the Workers'Compersallan provbloro ofthe Labor
CC
_ Code,you mast forthwith comply mthsuch pmvbiom or this permitshallbe TOTAL:
W deemed revoked. G ..
U p CONSTRUCTION LENDING AGENCY SEISMIC FEE
= Z Iherebya/Oren that there b a construction lending agency for the perform. ELECTRIC FEE
anm of the work for which this permit Is Issued(Sec.3097,Civ.C.)
TOTA .
V O Lender.Add PLUMBING FEE
U. H Lender.Addreu QTY, MECHANICAL PERMIT FEE
O W Icerti(ythatlhavereadthla appliutbnand Yalethatthe aboveinfomiatlon MECHANICAL FEE
6 incurred.I agree to comply with ai cttyand only ordinances and Yate laws PERMIT ISSUANCE FEES PAIL}
N relating to building conutrudloryand III authorize representatives ofthb
Z city to enter upon the above-mentioned property for uspection purposes. ALTER OR ADD TO MUCH.
V — (We)agree to uvq indemnity an If keep harmless the City of Cupertino Date Recel t#
agalmt BablBtb,judgmenb,c.Yeand expenses which may In any wayamme AIR HANDLING UNIT Cr010,ODOCFM)
agolrotsaldC in consequence of the granting of this permit SUBTOTAL:
��aa� hrt l �J� AIR HANDLING UNIT(OVER 10,000 CEld) CONSTRUCTION TAX
sig fc trAppu ad '�! Data '*' EXHAUST HOOD(rev/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
WIIltheapplicant or future building occupant store or handle harardous HEATING UMT(10100,00007"
materials.defined bythe Cupertino Municipal Code,Chapter 9.17,andthe Date Reuel t#
Health and Safety Code Section25532(a)? BEATING UNIT(OVER 100,000 BTU) TOTAL
Rill
No
Ill the applicant or lure building rampant use equipment ordevices
which emVEMDLAITON FAN(SINGLE RESID) ISSUANCE DATE
it haurdous ale contamlro nts as denned by the gay Arca Air
Quality Management District? BOILER-COMP QHP OR 100,OM BTU)
Yes ❑❑No '0
havercad l.Healthe h
Safety
mandrils roquitions 2menlsunderndChapter 2554. ) of BOILER-COMP(OVER IW,ODO BTU) AY
theerstan thatifth.bSafety Coes ran currently have
a tared,that I ®1
responsibility
that Uthe occupant
not erequir have which
that It is my NEW RESIDENTIAL MEIN. SQ.FI I/ a,9
reser to issuance
ce really theoccupantcethe requirements which ovnsth met' ^
prior to issuance da Certificate ofOmpanry. l'Y UFCup 1gg1
Owner or aulhorlud agent Date a�7�a
TOTAL: ISSUED BY
OFFICE COPY