22249 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Huudin Project Identification PERMIT NO.
Building Address: e D e 4Yl� ( V �
22249
IS SS'S' 6 fine. CITY OF CUPERTINO-BUILDING DIVISION _ / Cil
c°ntrato tName: Lt..No: APPLICATION 1 PERMIT ( C
• E \NAL) St s] N (p 111.v$ BUILD[NGF2.ECTRICALI'LUMBINGMECIiAMCA6 CATEGORY CONTROL.6
Archlte t/Engineers Llc.No:
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Address T.PERh11T ISSUANCE �,Q ❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S pr DECLARATION
[hereby
ection7000)olam Ecm3oftheard usiro andlsro Cssiona9(deanenc APPLIANCES-RESIDENTIAL - JOB DESCRB'.�ION
hooresh i.full7000)o(Dlvislon3afthe Bumnessandl'rvfesmoneCade,and my
license Is In(u3(pix ed effM. PANELS 1 �•
License Cla �•a'1.f Lic.0 Olt togs �J \ / 1/1
Date 6 Cmdrator F �Al SrfyA)&I p1-IOOOAMI9 —J ( V�
ARCHITECPS DECLARATION
reOZ I understand my plass shall be used n public records. OVERIODOAMPS SQ,FC.FLOOR AREA S/SQ.FC.
CO
(� Licensed Professional SICNS ELECTRICAL
r" -
OWNER-BUILDER DECLARATION SPECIALCEICUIT/MISC
X a I herebyaffimn that I am exempt fromthe Contractor's License Law for the
pq following reason.(Sefton 7W 1.5,Business and Professions Code:Any city or
KE'ut [ountywhichmqulmsapermittowmtmd,alteplmpmve,demotbh,ornpalr 7Eh1P.MLTITt ORIOLE[NSC.
5 ❑ anystructum priorto its issuance,also requinotheappllant forsuch permit to
a [OWER DEVICES
ryL U Oie a signed statement that he It Bcensed pursuant to the provisions of the '
3 w� Contractor.Lt..I..(Chapter 9(conurentng with Section 7000)of Divi- SWIMMING POOL ELECTRIC
O don3mthe Buelneneand Prof.t..Cod.).,th.thebexemptthemfmmand VALUATIONQ a
6 the bases for the alleged exemption. Any violation of Section 7031.5 by anyD •
O
applicant fora permitmOUTLETSSWITCHESFIXCURES subjects the applicant to a civil penalty of not ore than D
five hundred dollars($500).
�n ❑I,as owner of the property, NEW RESIDENTIAL ELECTR_SQ.Fr. SCOW TYPE CONSTRUCTION
p .,k,.or employees r their
compensation,Busionwill do theworkandthe Code:
In Contractorne Intended oroffered for
D sale(Sec. pply 70K to an owandf property
Cade:Tde or improves
hemor,Law
3S
does not apply torn owner of(prough wise Wimploymprorcoryand OCC.GROUP RES.UMTS
whodoementusuch ans workhimse dedorough hleowne.If,hms; er,theprovided ildinghat r
Improvement issold ithindeoyearo red plebe ,the owe,,buhebulWi have TOTAL: ,<1
Improvement beold wlthlnoneyearo(compltlorylh.ownervbullderwlllhave
thskurdenofpmvingthmhedld net build or Improve for purpose of sale.). QTY. PLUMBING PERMIT a EEI. FLOOD ZONE APN
LJ L as owner of the property,am exclusively contracting with licensed P LSSUA[VC u .
'rontrat°n to construct the pmjet($ee 7044,Business and I'm1fsabru Code: t
The Contractors License Law don not apply to an owner of property who AL'T'ER-DRAIN 4c VENT
Wilde or Improves thereon,and who contracts for teeth ptojets with a ' a FEE SUMMARY
�qBI actor(s)licensed pursuant to the Contate eLicense Law. BA FLOW 'I'R' 'bEL7
IJ I am exempt under Sec. H A P C for this reason '
Owner Date
DRAIN ROOF, SANITARY RECEB'f M
WORKMAN COMPENSATION i DECLARATION .I.0PER a SCHOOL TAX Y N_[-]I hereby affirm that I have a rnrtifWle of consent to eelhlnwm,ora RECEIPT Y
certificate of Worken'CompersatlonInsurance ma certified copy thereotisse. GAS.EA SYSTEM-1 INCA OUTLETS PARKFEE Y N
3800,lab C.) (�
P.11ry p W C.f- 3Q[j�.Q- 1 J RFGEHR Y
Com env 4y��—R x \ I_ GAS EA.SYSTEM-OVER4(EA) BUILDINGDIVISIONFEES
Certified mpyi,hereby furnished. GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHGCK PE•E [(
�Certlfied copy b filed with the city inspection division.
CERTIFICATE OFU MPCION FROM WORKERS' GREASE TRAP PAID 2– Z
COMPENSATION INSURANCE SEWER-SANRARY-STORM EA 200FC Date Receipt#
(This section need nt be comptted lithe permit Isfor ore hundred dollar
(5100)mless.) WATER IIFATLTt W/VEM/ELFiCTR ENERGY FEE Y_ N_
I certify that In the performance of thewmk f°rwhieh this permit Is blued,
I shall not employ any person M any manner not as,to become subject to the WATER SYSTEM/TREATING
Workers'Compematlon Gwtof GllfomiaPAID
O Z Applicant NEW RESIDENTIAL PLMB. SQ.FT. Date Recei t#
Z O NOTICE TO APPLICANT:ILafter making this Certificate of Exemption,you
should become subject to the Workers'Compenatlon provisions of the Labor TOTAL:
P:
N Code,you cruet forthwith comply with such provbtoro orthb permit shall be BUILDING QO
W Cm
deemed resolved.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE
Ihembya(firm that there b a constructions lending agency for the petorm TOTAL: ELECTRIC FEE O
M Z anre ofthe w°rk(or which this permit b Issued(Sec.3097,CIv.C.)
O O Lers er'.Name - PLUMBING FEE
LL I- Lendoet Address QTY. MECHANICAL PERMIT MECHANICAL FEE
OW Imdlfythatlhavemadthbappbatlonand Oatethattheaboveinformntio^
a Lscorms.Iagree tocomply with all city and county ordinances and tate laws PERMIT ISSUANCE FES AID•
>. relatingtobuilding construction,and herebyauthmrize representatives!this T- QZ 'ZZ
(— Z city to enter upon the above-mentioned property for Wpetl°n purposes. ALTERORADDTOMFLH. Date Reee1 t#
(We)agree to save,indemnify an d keep harmless the City of Cu ped Ino
V agairentllabNdee,pdgments,come and Menses whlchmuyinanywayamcue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aguicu ity In coneryucnce ofM ming of thio permit
/ !� AIR HANDLING UNIT(OVER I0,000CI'M) NSTRUCTION TAX
Sgnture of Applicant/Contractor W <s . EXHA(ATHOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUSMATERIA DISCLOSURE
Will the applicant or future building oevpant more or handle hazardous HEATING UNIT OO I OO,ODO HILI) Date Recel t#
material as defined by the Cupertino Municipal Code,Chapter 9.12,and the
Health and Safety Code Senors 25532(.)7 HEATING UNIT(OVER 100,000 BTU) TOL:
❑Yn �]No
Will the applicant or future building occupantuse equipment ordevices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit havurdous aircontaminant undefined bythe Bay Area Air 111111 SE CLj ��f}
Qu lily Management District?trict? BOILER-COMP OHPOR 10010HTN JON
4Yea ❑❑No
haveroad the hazzous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU)
the Calif°mrdia Health A Safety Code,Sections 25505,25533 and 25534.I ft Of
understand that if the building dons not currently have a tenant.that It b my NEW RESIDENTIAL MECH. SQTT 17
responsibility to notify the occupant qQhe requirements which most be met
prtort ceofa di(Ia1e o(O ancy. '
Q: - �/ 9 ,
Owner or authmlud agent - ate TOTAL, ISSUED BY:
OFFICE COPY