22554 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES— USE BALL POINT PEN ONLY
Bundles ?,.led Identification PERMIT NO.
BaOding TS S aa: / 22554
B2 Dr
s ams: e: A
Q S-0A) jr2^ l5' CITY OF CUPERTINO-BUILDING DIVISION
C do °Name Lk
Name: APPLICATION /PERMIT /
Gtr77 BUILDINGELECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROL 0 ��
rch tM Engimer. Lic.Na:
4bf'k A100416 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address PERMITISSUANCE
LICENSED CONTRACTOR'S DECLARATION ® E D 0
1 hereby affirm that l am licensed under provisions of Chapter 9(mmmene- APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwith Section70001of Diviston3afthe Budn and Pmfe onsCode,and my
License is In fu os6e cad dfeR..�.2�• PANELSLue 're�
Do. V Lle p Y
Date Contractors co
ARCHITECTS DECLARATION 701-1000 AMPS � SVK
µo!09z I understand my place shall be used as public records. OVERIMOAMPS SQ.FT.FLOOR AREA $/SQ.FT.
E Licensed Professional. SIGNS ELECTRICAL
L 6 OWNER-BUILDER DECLARATION 0(T Y
I"n SPECIALCIRCIRT/AtISC
t.. I hereby af(Irmthat I am exempt from the Contractor's License Lw for the
following reason.((Section 70315,Business and Professions Code:Any city or TEMP.METLI60R ]NST.
P F' muntywMchrequlrcsaper twmmtmd,ilMr,impmve,demoiahormpalr ' -
S� < any atmdurepdortoleslass.neqalsorequimatheappllcantforsuchpermlttoNALLU
P O V fit,a signed statement that he b licensed pursuant to the provisions of the ]OWER DEVICES
W6 a, Contractor's License law(Chapter 9(commencing with Section 700))of Divi. SWIMMING POOL E C
slon3ofthe Bustnessand Professlace Code)orthatheisexempttherefromendas a
VALUATION_/I the basis for the alleged exemption. Any violation of Section 70315 by any lJ(/
appllnnttoraper tmbjedstheappManttoadvllpemitydnam mthan OUTLETSSWI7'CHF'FT�XXTaU�RFS
five hundred dollars($500). NEWRESIDENTIALELMATEV ll
❑I,as owner of the property,or my employees with wages as their sole RIES TYPE CONSTRUCTION
compensation,will do the work and the stmeture In rest Intended or offered for
O 'sale(Sec 70K Business and Profealoce Code:The Contractor's Llcecee Law
$ does net apply to an owner of property who builds or Improves thereon,and OCC.GROUP RES UMTS
who does such work himself or through his own employees,provided that such
improvemenbare not Intended oroQered forsale.If,however,the W ilding or TOTAL:
Improvement issold wlthln mayearofcompletioo,the owner-bullder wlil have
thLyarden of proving that he did not build or improve for purpose of sale.). QTY, PLUMBING PERMIT FEE FLOOD ZONE APN
LJ L as owner of the Property,am exclusively=trading with licensed PERMIT NUANCE
mntredors to construct the project(Sec.7014,Business and Profeabm Code:
The Contractor.License Lw does next apply to an owner of property who ALTER-DRAIN Is VENT WATER(Eq)
Wilds or improves thereon,and who contracts fee such pW*u with a FEE(SUMMARY
10 ttMador(s)licensed pursuant to the Contractor's License Law. BACK FLOW PROTECT.DEVICE
L5 I am exempt under&r. B&P C for this count,
DRAINS FLOOR,ROOF,AREA,GOND, SANITARY Y N Owner Date RPGFJPTN
WORKMAN COMPENSATION DECLARATION H%•NRES PER TRAP SCHOOL TAX Y N
0
1 hereby affirm that I have• I rt con of consent to opytheself-hosore,ora RECEPI7 M
certificate o(Worken'CompeceatlanIceuesnce oracertlfled copytherm((Sec3800 Lab C) . GAS EA.SYSTEM-1 INCA OUTLETS PARK FTE Y N
F. CEIPT N
Cc a �� _'� GAS EA.SYSTEM-OVER 6IRA) BUILDING
Com any � BUILDING DIVISION FEES
Certified copy B led with the cityed. �� GREASE/NDUSTRL WASTE INTERCEPTOR PLANCHECIC FEE
Certified copy la filed with the city inspection division. 6
CERTIFICATEOFEXEMPTION FROM WORKERS GRE'A5E7RAP PAID v
COMPENSATION INSURANCE SEWER-SANITARY-STORM FA]010-1' Date Recei t#
(This section need net be completed B the permit Is for one hundred dollars
(9100)orlm.) ENERGY FEE Y N
I certify that in the performance of the work for which this permit is Issued, WATER HEATER W/VENT/ELECTR —
I shall not employ any person in any manner n as to become abject to the WATER SYSTEM/TREATING
Workers'Compensation California.aws of Califo .Date PAID
-
0 Z Applicant NEW RESIDENTIAL PLMB. SQFT. Date Recel t#
Z O NOTICETO APPLICANT:It,after making this Certificate of Exemption,you
should become subject to the Workers'Compensation provisions of the Labor TOTAL:
ccN CDde,youmustforthMthmmplywlthsuchpmWlamorthbpen tsMibe BUILDING 00
W'7 deemed revoked.
CONSTRUCTION LENDING AGCNCY SEISMIC FEE x D
a z Thereby a(fimnthat there is a mnatmdlon lending agency forthe perform ELECTRIC FEE
Z anceoftheworkf.,whichthbperndtisLamed(Sec3097,Clv.C.) TOTAL:
V O Lenders Name PLUMBING FEE
LL F Lender's Addreaa QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
O W 1certify that l have read this applicatlonaod state that theabove information
bmrrect.l.greelacomply with all cityand county ordinances and state law° PERMITLSSUANCE FEES PAID:
>. 1 N relatingtobuilding mout=on,and hereby authorize representativeaafthb
cityto enterupon the above-mentioned propertyfor Inspection s ALTERORADDTCMECH.
~ z (Wr)agree to save,Indemnify an d eehadess te City purposes.
nlno Date Receipt#
V against liabnines,judgments,costs and expenses which may In any way accrue AIR HANDLING UNIT(TO 10,ODO CPM) SUBTOTAL: —0
ag.icetax C In consequence of the g of this permit.
AIR IiANDLING]INR(OVER 10,001)CFM) CONSTRUCTION TAX
'SigdAu.o( pp cant/ .M.Cor Our; EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orfumm building occupant store or ha cad le hazardous HEATING UNIT(TO 100,000 BM Date Recel t#
material as defincd by the Cupertino Municipal Code,Chapter 9.IZ,and the
Health and Safety Code Section 2553X.)7 HEATING UNIT(OVER IOO,ODD BTU) TOTAL: .or
Fly. No
Will the applicant or Wrebcild(nga panluxequipmentordevlma VENTILATION PAN(SINGLE RESID) ISSUANCE DATE
which emit hamrdom air contaminants as defined by the Bay Area Air !�
Quality Management District? BOILER-COMP D}IP DR 100,000 B7U1 PAM
Yea (�No
have read the hazar`fious materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) /
the California Health&Safety Cade,Stolons 25505,75533 and 75536.1' /'_' f4, �19�r
understand that if nth. the occupant
net ourequire encs which
that b Ls et NEW RESIDENTIAL MECH. SQFf. �,�
ropy to Issuance
ce ndifythe oam:,I tofthe requirements which must be met /fir
prior to iauanma Certificate cev�I W�/�
s
n or auff3riard agent to TOTAL: ISSUED BY:
OFFICE COPY