20922 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect IdentificatlioonnR PERMIT N20922
//O..,- 01
Building Addnm:�OtO 2 0 9 2 2
ww . vre: one: A .
G �rouq qq6^ZSrr o CITY OF CUPERTIN6BUILDING DIVISION 1200
• Cantractor'.N.me: Lie.No: APPLICATION'/PERMIT I
ArchltM/Engineer. Llc No: BUILDING-ELECTRICAILPLUMBINGMECHANICAL CATEGORY CONTROL#
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION
IMreby aSt.that l amlicensed under provlgo...fChapter9(commenc. APPI]ANCESRESIDENTUL J00 DESCRIPTION
inensei in fan to=o Division fect. the Bugrsuand ProfeegonsCode,and my
license le In lull force and c.0 .I PANELS
License Chu Lic.p
Date Contractor
ARCHITECT'S DECLARATION 201-1000 AMPS
q�q�uu N Iunderst.od my plans shall be used u public mounds. OVERIOOOAMPS /�k SQ.FT.FLOOR AREA $/SQ.FT.
[ti O SIGNS ELECTRICAL 800 T "a ?�d l
<<� Licensed Professional 'C
Q OWNER•BUILDER DECLARATION 11100-4TSG•~ Zo a�0
rii] SPECIALCIRCU[T/MLSC
I"'Yil I herebyafllrm that I am exempt!menthe DECLARATION
Llmnu Gw(or the
po !allowing rectum.(Section 70315,Business and Professions Code:An d or
O Z t. 7 city TEMP.MEUR OR POLE INST. '
�� anystmcounty mph rlmapermit wancomnutequim.er,Improvgdemouhpe Oair to
any structure statement
that he is aLw rsed pursuant
t the provisions
of t e POWER DEVICES
14 a signed License
he t licensed pursuant it the proWlou of the
3w Mon3ofthe urines arAPmupter9(mm).,thgwBhSection mpttherefolDlvl-
��OS mon3olthe Buslnmand ProfmlouCode)orthat heb ewmptthere(romand SWIMMING POOL ELECTRIC L
0 5 the basis for the alleged exemption. Any violation of Section 7011.5 by any OUTLETS-SWITCHES-FIXTURES MOD
applicant fora permit subjedatheappllunt to n civil penalty of not more than
five hundred dollars(S500).
[ as owner of the property, NEW RESIDENTIAL ELECTR SQ.FT. STORIES TYPRCONSTRUCTION
�n ❑, p perty,or my the is net
as
com(Sec.lion,Businesswill do and Professions,Code:
Tim otrntended License
Law
d for
O dole(Sec.apply
to an ow and Pro(mWrs who builds
or improta Liceme Law
$$ wonotapply torn owner ofpropertyhiswn emsorimprovnted that such
OCC.GROUP RES.UNITS
whodaementsas such orkhimseEedoroffe hisow ice If, owe prmidedthatsuch
improvementsarenotintendedproffered(prole.If,however, deer fll have TOTAL:
Improvement lseald wlthlnomyearolcomplmlon,theowner-bullderwW have
t
to of proving that he did net bulla or improve for purpose o(ule.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
L as owner of the property,am exclusively contracting with licensed
n Ron'to construct the project(Sm 7046.Business and Professions Code: PERMIT NUANCE rz,av
Contractors License Isw dose not apply,t.an owner of property who ALTER-DRAIN A VENT-WATER(EA)
builds or Improve therean,and who mmracia for such tufalee,with a FEE SUMMARY
�yTTador(s)licensed pursuant to the Contractor's License Law. BACK PIAW PROTECT.DEVICE LJ I am exempt under Ser B k P C for this mown
' .
DRAINS FLOOR ROOF,AREA,GOND. SANITARY Y N Owner Date RECENT a
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP /�a SCHOOLTAK Y_ N
01 hereby affbm Net I have o Insurance
or cmsent to opy there or • Ta'J RFCEIPT#
3800,Let,certificateC.) rken'Comperwtlon lruuranro oracertlflM mpythereolt5ac. GAS EA.SYSTEM-1 INCA OUTLETS eZadD PARK FEE Yr N
Policy GAS EA.SYSITM-OVER RECEIPTa
Com any BUILDING DIVISION FEES
�CertNed copy is hereby te
Cdrtilled mpylsfiled withh the city
inspection division. GREASE/P)DUSTRL WASTE INTERCEPTOR PLANCHECK FEE
� ty �-��j}�
CERTIFICATE OFEEM PTION FROM WORK ERS' GREASE TRAP PAID `Q' o n" 51 jr mm..{`
COMPENSATION INSURANCE SEWFRSAMTARY-SANITARYEA 200F7 Date Recei t# STI,3b
(Ihlaeection need na 4 cwnplRed Bihe permit ls for ow hundred dollars
(9100)orie.s.) WATER HEATER W/VENT/dECTR ENERGY FEE Y N
I cortifythat lo,the performance olthe work lorwhlch this permit is tested,
I shall nor employ any person to any runner an ex to become subject to the WATER SYSTEM/TREATING (� �s may, /�`� -s
Workers'Compensation Laws of California. Date PAID D2/-TL1 7 1511 Ol r�.
Z Z Applicant NEW RESIDENTIAL PLMB. SQFI'. Dale Rece1 t#
NOTICE TO APPLICANT:R,after making this Certificate of Exemption,you
should become wbject to the Workers'Compensation provistom of the Labor TOTAL: 0;3
CCN Code,you most forthwith comply with such provisions or this permit shall be
Wj deemed revol a 1.
aCONSTRUCTION LENDING AGENCY SEISMIC FEE
I herebyafftrmthat there is acoutrottlan lendingagency forlhe perform- 3ELEGTRIG FEE
Z an of the work lorwhlch this permit la iuued(See.3077,Civ.C.) TOTAL: YJ
U O =Mxe.Name PLUMBING FEE
LL Uruice.Addreu QTY. MECHANICAL PERMIT FEE MECHANICALFEE
OW Icertlly thatl have read lhbapplicadomand gate thattheabovelnformation �,,)
W lsromct.I dgreeto comply with all cttyand county ordinances and gate laws PERMIT ISSUANCE �(�(/ FEES PAID:
T relating to building construction,and hereby authorise representatives ofthls
H U) city to enter pan the above-ex caned property for inspection purposes. ' AUIER OR ADD TD MECH. s�}'
V _ M'e>; to save,1 n an d keep haDNm the city of Cupertino Date Recel t#
agabstl I In,judg n1. sand expenses which may In anywsyacaue AIR HANDLING UNIT([D 10,000 CFM) SUBTOTAL:
agaW Ityta a 9<' the
granting of)ipermit
AIR HANDLING UNIT(OVER]O,OWCFM) CONSTRUCTION TAX
Sigotu !Applin sent cur Date EYHAUS'THOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARD S A RIALSDISCLOSURE a
Will the applicant or lutum bull ngoavpant store or handle hazardous BEATING UNIT(TO 100,000 BTU) LL Date Revel t#,
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
Health and SafetyCode Sedion 25532G)7 HEATING UNIT(OVER 100,000 BTU) TOTAL: O
❑Yn No a
Willths Sppllcanior tore building occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSI.R1509ATE
which emit haordous air contaminants as defined by the Bay Area Air
Gas fifty Management District? BOILEWCOMP DHP OR 100,000 BTU) �� 19�a
❑Yes ❑No v
(have read the hazardous materials requirements under Chapter 6.95 of BOILER-Comp(OVER100,000 BTI!)
the California Health k Safety Code,Sections 25505,25533 and 25539.1
understand that lithe building don not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQA-? ssj I
responsibility to notify the occupant of the requirements which const be met
prior to Luuance of a Certificate of Occupancy.
Owner or authorised agent Date ���+' 6- s .,'#.6
'TOTAL: ISSUED BYt \UCJ�{{T�'•-aY"O�`"�LS -
OFFICE COPY