22615 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Pro'ectldMi(IcaHon PERMIT NO.
Building Address:
o ov f 22615
ame: ona,
- SD pl CITY OF CUPERTINO-BUILDING DIVISION
cont It am: eW / APPLICATION / PERMIT L
GaC.
Ards ed En ne r BUR.DINGELECTRICAL-PLUMBING-MECIIAMCAL CATEGORY CO Lp
Llc.No:
/ ''') QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: a/� /(, (� PERMIT ISSUANCE V O ❑ [X2.1. ❑ ❑
LICENSED CONTR CTOR'S DECLARATION
I hereby offlan that l sat licensed under provisions of Chapter 9(cammenc APPLIANCES-RESIDENTIAL JOB DESCRIPTION
Ingwrte lth SecHon7000)of Di t.ion3ofthe BusimssandProfeaatomCMe,andery
licence le In full toand effect. PANELS
Data
Date Contra ar
AACHITECTSDE RAT N OVER
AMPS
aO Zp Iunderstand my plaashaEbe used as public temrds OVER 1000 AMIs5 SQ.FT.FL AREA S/SQ.FT.
b Licenced Professional SIGNS ELECTRICAL A L E D
�CU+1 OWNER-BOLDER DECLARATION &� P T
>/i 2 a SPECIALCIRCOT/MLSC'
Z s,Yl I herehy a(flrtnthat I amexempt from the Contrador'e Lirens law forthe - ,
following reason.(Section 7031.5,Businessand Pro(essl-a Code:Any city or
O p. TEMP.METER OR POLE]NST, —
F� oountywhkh requlnea perMttocoatruct,alter,Improve,deanlbA,orrepatr
4 anystrudumprlortoibW amt alsorequtmstheappBant(orsuchpermitto POWER DEVICES
file a signed statement that he Is Borated pursuant to the provisions of the .
(Qj 3 O Comradole Litems Law(Chapter 9(--.dcg with Section 7000)of Dlvi. SWIMMING POOL ELECTRIC
don3 ofthe Businessand ProfessloroCoda)car Nat he is exempttheretromaM � ALU
the basis for the alleged exemption. Any violation of Section 70315 by any OUTLE'ISSWITCHE&F1XTURFS 1 `�.J � R
O5 applicantfor&permit subjects the applicant to a civil penalty of no morethan �'�f� p 6�
$ five 1,as owner
neroftdollars( NEW RESIDENTIALELECTR �j.Ff. e/ TYPECO SIRUCTION
�n ❑Lasownerlt theproperty,ormyemtiam inwithwages r their win DAT `'/
.1.(Sec.
Secompen.7044,Business
wort,and thesC durehe Contractors lotendM-r tensoffered for
O doe es not
apply
to alnow and ProfessWm who
Code:The orImpmethe me Law
$ whodoe apply work owner ofthroug his o buinemsorlmprovnthereory and
whadceaeuchwarkhimself orthrough hieownemployen,provldM that such OCC.CROUP RES.
IINE'S-
improvementsare not intended orofferadtorsafe.If,however,thebullding-r TOT' ,O
improvement baold withinomyearofcomplmbrytheowner-bullderwlll have
thLtlurden of proving that he did not build or Improve for purpose ofsate.). QTY. PLUMBING PERMIT FEE
U L as owner of the pmpery,am exclusively contracting with licensed FLOOD ZONE APN
PERMIT ISSUANCE
mntradu r to construct the,project(Sec.70K Business and Professions Code:
The Contractor's Llceme Law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EAI
builds or Improve thereon, and who contracts for such p(oects with a FEE SUMMARY
Tt(+ctm or(s)licensed pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE
J 1 a ...-Pt -Mer Sec. B h P C for this rcawn
OUTSI Do FEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N
Owner Date RECEIPT M�
WORK MAN COMPENSATION DECLARATION FDnIJRES PER TRAP SCHOOL TAX Y_'N
QI hereby oraffirmthat I have• I N cone of a mu ill d self-inerre,ora RECEIT T N
3800,LaeofWorken'ComperuaHonlmuranceora certified copytherro((Sec. GAB-EA.SYSTFM-]INCA OUTLETS PARK FEE Y N
3800,Lab C.I RECEITT 0
Policy tl GAS EA.SYSTEM-OVER d(EA)
Com Cert any BUILDING DIVISION FEES
ffIfled copy's hereby fumished. GREASE/INDUS WASTE INTERCFTTOR PL.ANCHECK FEE
®2k�Bled copy Is filed with the city impedion division.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASETRAP PAID
COMPENSATION INSURANCE SEWER-SANTTARY-STORM F.A.200FT Date Recti t#
CThlssectlon need not M completed lithe perndt t,for one hundred dollars
($10(i) WATER HEATERW/VENT/ELECTR ENERGY FEE Y N
i) ,I ,)
Iin the performanceollhe wmkfor wNch this permit is lowed,
1 shall not employ any person In any manner so as to become abject to the WATER SYSTEM/TREATING
Workera CompewHon Lawsof California.Date PAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT'.s Date Recef tp
Z O NOTICE TO APPLICANT:If, making king this Certificate of Exemption,you
should become Subject to the Workers'Compensation provision;of the Labor TOTAL:
W Code,you moat forthwith comply with such provision orthis permit shall be B I G
LMFEE
j domed revoked.
CONSTRUCTION LENDING AGE ICY SEISMIC FEE
CLO Iherebyaffirmthat there b a construction fending agency for the pedorrry ELECTRIC FEE
7 Z once-(the workfor which this permit is hwed(Sec.3097,Civ.C.) TOTAL: Z-UQ
00 lenders Name PLUMBING FEE
LL ~ Lender'sAdd. QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
OO I certifythat l havereadthlsapplicatlon and statethatthe above information
1 bcornect.I agree to complywlth all cityand county ordinances and state laws PERMIT ISSUANCE FEES PAID:
>. N relating to building construction,and hereby authorise representatives ofthis
F Z city to enter upon the abovem
- entloned property for Impaction purposes. ALTERORADDTOMFGH. Date Recti [b
(We)agree to save,indemnify an d keep harmless the City of Cu pe Lino
V against llablikes,' dgmente,coNsandexpen which rtuy In snywaya a AIR HANDLING UNIT(T010,W)CFM) SUBTOTAL:
ag.imtsaid ens the Is pemmt.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
estate of Appli
I
ontractor Dae EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
XA2ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harardous HEATING UNIT(TO 100,000 BTU) Date Recei tN
materul as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Section 25532(a)I HEATING UNIT(OVER 100,000 BTU) TOTAL:
❑ Yee N No
Willtheappllcant or future building occupant use equipment ordevices VENTILATION FAN(SINGLE RESIO) ISSUIRRHUXTE
which emit hamrdous air contaminants as defined by the Bay Area Air
. Qu a llty Management Dist do? BOILER-COMP OFR'OR 100,000 BM ��� 0 as
4 readthehasa oYea N No
haveus materials requirement,under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the California Health k Safety Code,Sections 25505,25533 and 25534.1
understand that lithe building don not arrently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT RIIB�QJ
resporulbWty,to ndl(y the occupant of the requirements which most be act
prior to Issas nm of a Certificate of Omupa eery. !I L(I��•
Owner or authorised agent Date TOTAL: ISSUED BY:V•_t! `�'4�'�
OFFICE COPY