22120 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building project Identification PERAUT NO.
Building Address 22120
I DI aPJ l refs 1✓
Phone:
ee
name J �. CITY OF CUPERTINO-BUILDING DIVISION
"a
Cnn "°r'a2 re 7� Lic.No: APPLICATION /PERMIT
J BUMDING-MECTRICALPLUMBINGMECHAMCAL CATEGORY CONTROLN
Architect/Engineer. Lk.No:
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address I'ERhtITISSUANCE ❑ El a [ILICENSED CONTRACTOR'S DECLARATION
I hereby hSedi n7Olhatlam Bcrosedunder provbionsof CatonsC(commme- APPLIANCESREADENfWL JOB DESCRIPTION
Inense Heflin to. iteect. oflheBuelmuand Fro(easionsCade,and my
license b in foil fors end effect PANELSLic
Dat Claes Uc N
Date Cantndar '
ARCHITEC7.S DECLARATION 2II-1000 AMPS
9U' Z I understand my plans shall be used as public records. OVER1000AMPS u ��Fr.FLrfgEA $/SQ.Fr.
ELicensed Professional SICNSELECTRICAL ,� N
cid OWNER-BUILDER DECLARATION T E R
!`n SI'ECIALCB2CNT/MLSC
owing yaWrmnthelon 7031mptlromthe Contractors License lawforlhe
followingreason.firma n7mitto Business and PImprom, Ce:Anydty,it
O s:� TEMP.METER OR POLE INSf.
P� countywhirh rcqu4mapermltromrutmct,alter,Impmve,demolish,orrepalr A
q11 any structure prior to Its Issuance,also requires the applicant for such permit to ]OWER DEVICES DAT
file a signed statement that he Is Bsnsed pursuant to the provisions of the
G13 1 0 e (Chapter License Law (commencing
with
edm sWQdh9NG POOL ELECTRIC
e1on3 ofthBuideadend PmfelmuCImthtt heb xempt thrmd VALUATION
the bash forthe alleged exemption. Any violation of section 703IS by any OULLETSSWITCHESFIXTURES
applicant fora permit subjectatheappllcant to a civil penaltyof not marc than
(ly�hyndred dollars(550Q. - NEW RESIDENTIAL ELECTR SQ.Fr. STORIES TYPE CONSTRUCTION
�n as owner of the property,or my employees with wages as their sole
X
adon,willdolhe work and lhesbucture isnot Intended or offered for
❑ vie(Sec.70K Busbies and Podessimu Code:The Contractor's License law
�$ does not apply to an owner of property who builds or Improves thereon and OCC.GROUP' RES.UNTFS
who doessuch work himself crthrough Ms own employeed,provided that such
Improvements an,not Intended oroffered forsale.If,howevepthebulldinger TOTAL: -
improvement b sold within aneyearof completion,the ownerbu0derwlll have
t rden of proving that he did not build or Improve for purpme o(sale.). QTY. PLUMBING PERMIT FEE FLOOD ZONE APN
UL as owner of theproperty,am exclusively contracting wish lim d pp pT e�UANCE
contractors to construct the project(Sec 7044,Business and Profemion,Code:
The Contractor's Lienee Law docs no apply to an owner of property who ALTER-DRAIN k VENT-WATER CEA)
builds or Improves theresuch -
on,and who contracts for
ptojects with a TFEE SUMMARY
&or(.)lammed pursuant to the Commerce.License Law. BACK FLOW PROTECT.DEVICE
J I am exempt under Sec B h P C for this means
•
OUTSIDE FEES
Owner
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N Dare BBC=#
WORK MAN COMPENSATION DECLARATION �.N�M.�a SCHOOLTAX Y N
❑I hereby affirm that I have o ce durao of consent to copy
thereof
ora RECEPr N
mrfificateLab of Workers'Compensatlonlnsurance oracertifbd copythenmf(Sec. GAS EA.SYSTEM-1 INCAOUTLETS PARK FEE Y N
Policy
Gla C.)
Policy Y RECEIPT N
CGAS EA.SYSTEM-OVER 4(RA)
om Cany - BUILDING DIVISION FEES
rl Certified copy ertified copy b hercbytumbhed. CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
� b filed with the city inspection division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE gE(ygR-ggFRT;U(y-SR7RM EA,2001717. Date Remi t#
(rhi.sectlon need not he completed If the permit b foroes hundred dollars
(f100)orless.) WATER HEATER W/VENT/FJ CC.I.R ENERGY FEE Y N
I certify that re the performance of the work(orwWch We pernit is hued,
I shall not employ any Person in any manner u as to become subject to the / WATER SYSTEM/TREATING PAID
Workers Compensation laws of California. Date /
0 Z Applicant NEW RESIDENTIAL PLMB. BQFr. Date Recei t#
Z 0 NOTICETO APPLICANT:If,after making this Certificate of Exemption,you
rkers'Compensation provisions ofthe Labor TOTAL:
shouldbemmesub)ecttothe Wo
N Code,you mustforthwith comply with such provisions orthis permit shall beCC — BUI
W LDING FEE
y deemed revoked.
a t] CONSTRUCTION LENDING AGENCY - SEISMIC FEE
(Se
IberebyafBrm labu
that there b a construction lending agency forthe perform - TOTAL: ler ELECTRIC FEE
M O a.a.flheworkforwWhthbpermitedc3097,CIv.C.)
I..data Name PLUMBING FEE
LL F Landers Address QTY.I MECHANICAL PERMIT FEE MECHANICAL FEE
. OW I certifythat I have readthb application and stttelhattheabove Information
CL Iscorrect.I agree to complywith all dayand county ordinances and date laws PERMIT ISSUANCE FEES PAID:
rrelating to building mmtrudlon,and hereby uthorlu reprosentattvesaf this
W
I" city to enter upon the above-mentioned property for Inspection purposes. ALTLRORADDTOMECH.
Z (We)agree to save,Indemnify and keep harmless the City of Cupertino Date Rece) t#
V agaWtllabWliea,judgment,coats and expenses which may In anyway acme AIR HANDLING UNIT(T010,000 CFM) SUBTOTAL:
against d Incor, ence of the nI gofthis pemit.
AIR IiANDDNc UNIT rovRR lB,000cFhD CONSTRUCTION TAX
sign ( pplicant/Conted or Data EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERI SDISCLOSU E
Will the applicant orfWure building occupant store or handle hazardous HEALING UNIT(TO 100,000 BTU) Date Recei t# 1.
material as defined by the Cupertino Municipal Code,Chapter 9.1 7,and the
I lealth and Safety Code 'On
7S537(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑Yes No
WWthe Sppllont or turebullding occupant use equipment or devices VENTILATION FAN(SINGLE RFSID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air
Quality Management District? BORER-COMP DFB'DR100,0008'M
Yes ❑NO
have rda ealth&rcaletyC de,S requlreme5,2553eand 255 4.1 a(- BORER-COMP(OVER 100,000 BTU)
the GOandt HealthkSafety Code,not
25505,ve a tandt,Shad.I
msponsunderstandy to if notify the cc doespant not emquiyments which
that It mets my NEW RESIDENTIAL MECH. SQ.FT.
prior to issuance
c of a Cthe occupant o(thercquiremenb which must be met Q
prior to issuance o(a CertlOmte o(Oavpanry. ��'Lyy,�}���-j["�'�aLa.�/('.�}L,LLL,''"'
Owner or aulhmiaed agent Data 154IIED BY:4 `� ""')
TOTAL:
OFFICE COPY "