22588 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Project Identification PERMIT NO.
Build Ing Add ress: ` \ 22588 2r
re ante: one: APPLJCAff0NTU9rV=A MM
( CITY OF CUPERTINO-BUILDING DIVISION prj�-Z
o ano'sN LIC No, APPLICATION 1 PERMIT UU
Architect/Engineer: :o Q BUILDINGELFCTRICALPLUMBING-MECHANICAL CATEGORY CONTROL#
Lk
QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMITISSUANCE SCI ❑ ❑ ❑
LICENSED CONTR under provisions
I hereby thSedlOA700hatlamlicensed sim3oftheB sins aAdPmfeWm r9de.and c- APPLIANCESRESIDENTIAL JOB DESCRIPTION
incense Is
fullfore,of Divislon3ofthre�Bucs�inevand Pro(essionsCode,and rtry
license lsinle fes and affect'
-H9JZV-3>Q PANELS
Lkensc Cla Li[.N 11.E
ale_ Contranorq.h!Af - ROCC (Ta100 0-)
ARCHI=S DECLARATION 201-1000AMPS
07. I understand my plamshallbe used as publcrecords, OVERIODOAMPS SQ.FT.FLOOR AREA $/SQ.F(.
ALED IN
m b o Licensed Professional SIGNS ELECTRICAL
6 OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/#LSC
g. Z Iherebyafflrmthat l am exempt from the Contractor's License Law(w the M P UTE R
>-9 following reason.(Section 70315,Business and Professions Code:Any city or
GMf"e( county mquirnapenNt tomnstrun,alter,bnprove,dennlbh,or repair TEMP.METER ORIOLE[NST. � �� ��
`5 3 any strumcare prior to its issuance,a Iso requires the applicant for such permitto
c. file a signed statement that he is licensed pursuant to the provisions of the POWER DEVICES
3 c Contractor'.License Law(Chapter 9(comncndng with Section 7000)of Diet. SWIMMING POOL ELECTRIC
O smn3ofthe Businosand Pmfxxd to Codb
a)mthat heexempttherefromand VALUATION
&�.'S the basis for the alleged exemption. Any violation of Section 7031.5 by any
appaon
Mo 5 OUTLETSSWETCHESFIXTURES
$�o t(ora permit subjects applicant civil penalty of no more l Q0
Bee hundred dollars($500).
z�n ❑I,as owner of the NEW RESIDENTIAL ELECTR SQ.FL
pcompensation willdo the wark,and ormy, employees isnot intended swithwago roffered d for STORIES 7YT'E CONSTRUCTION
5 O sac(Sec.704Zapply
toflagrant.
ow and Professrty Code:The or imptlots Licerse law
$$ docs not apply to an owner of property who n lids or improves thereon,and DEC.GROUP RES.UNITS
who does such
ds,amwork
ntintelf or dedorough hisowge.If, owep ,theb builhat ding
improvementsarenotrntenaneorof(eredforsale.ILh ne�-gthebuildingve TOTAL:
improvement Issold withinoncyearo(complciiogthe owner-bulderwillisave
the rden of prevmg that he did not build or improve for purpose ofula.). QTY- PLUMBING PERMIT FEE FEDMNE APN
Li L as owner of the property,am exclusively=trading with licensed PERMITISSUANCE
contractors to construct the project(Sec.7044,Business and Professions Code:
The Contractor's License law does not apply to an owner of property who ALTER-DRAIN&VENT-WATER(EA)
Wild.or Improves thereon, and who contracts for such ptojem with a
m nor(s)Rearmed pursuant to the Contractor'sLicense Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exempt under Sec. B&P C for this reason
• OUTSIDE FF
Owner Date DRAINS-FLOOR ROOF,AREA,COND. SANITARY Y— N_
WORKMAN COMPENSATION DECLARATION RECEIPT#
01 hereby affirm that I have a artifiate of consent to calf-insure,ora FIXTURES PER TRAP SCHOOL TAX Y N
certificate of Workeni Compensation Insurance or a certlfled copy thereof(Sce. RECEIPT'#
3800,lash C.) GAS EA.SYSTEM-1 INCAOUTLEfS PARK FEE Y N
Policy# RECIR'I'p
Com any GAS EA.SYSTEM-OVER 4(FA) BUILDING DIVISION FEES
�Cenificd copy is herebyfurnished.city
GREASE/INDUSIRL WASTE INTERCEPTOR PLANCHECK FEE
❑Certified copy V filed with lM city Irspenlan division.
CERTIFICATE OF E)(EMPFION FROM WORKERS' GREASE TRAP PAID
b a
COMPENSATION INSURANCE SEvvFRSANTTARYSIORM EA 20oFI Date Recei t#
(fhnion need not W completed if the permlt k r
forone hundred dollars
(SINandyth) WATER HEATER W/VENT/ELECTR ENERGY FEE Y N
I snot em t o any person
in anf tm mannworker
an as to b co eenNt is issued, —
I shall not employ any person in any manner at u to become subject to the
Worken'Compensatlon laws or CaR(ornla. Date WATER SYSTEM/TAFATING PAID
O Z Appliant
ZO NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you NEW RESIDENTIAL PIMB. SQFf. 'Date Recel t#
Fshwldbecomesubjecttothe Workers'Comprastlonprovisioroofthe Labor TOTAL:
C W Code,you most forthwith comply with such provisions orthis permit shall be
LU > deemed revoked. BUILDING FEESL
4. p CONSTRUCTION LENDING AGENCY SEISMIC FEE
I hereby arfirmthat there V a corstmmction lending agency forthe penornF :
0 ance of the work for which this pard is Issued(Sec.3097,Civ.C.) ELECTRIC PEE
TOTAL
O lander.N. PLUMBING FEE
IL H Landers Address QTY. MECHANICAL PERMIT FEE
O W Iretilythat l have madtMsappiraHonand athbov
ateattheaeleformation MECHANICAL FEE
a Iscorrect.Iagree to comply with all my and county ordinances and state laws PERMIT ISSUANCE FEES PAID:
} N relating to building corstmerlon,and Mreby authorim representatives of this
I— Z city to enter upon the above-mentioned property for bspection purposes. ALTER OR ADD TO MECH.
(Wa)agree to save,Indemnify an it kap harmless the City of Cupertino Date Receipt#
against llabiRties,judgments,units and expenw9which may inanywaymeme AIR HANDLING UNIT 0.0 to," SUBTOTAL,
a afirst said City in ronuquenceof the granting a this permit.
AIR HANDLING UNIT(OVER lgOoa CIM) CONSTRUCTION TAX
Signaler ppilant/Contractor Data lEXHAUST HOOD(W/DICT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE 16-0 l�
Will the applicant or future building meta ant store or handle hazardous HEATING UNTT(TO 100,0(10 BTU)
mammid.sdcilmdby the Cupertino MuNdpal Code,Chapmr9.12,andthe Date Recei if
Neagh and Safety Cade Scnion 25532(a)7 HEATING UNIT(OVER 100,000 BT
LB L`J No U)
TOTAL:
Will the applicant or future bnllding occupant use equipment ordevices VENTILATION FAN(SINGLE KESID) IS$(�l[�I DATE
,which emit hazardous air contaminants as defined by the Bay Arca Air ILAtJB1
Quality Management District? BOILER-COMP OHP OR 100,0W BTU)
4 Yes No
have readtheham esusmaterials"uimmnhunderChapter6.95of BOILER-COMP(OVER 100,000 BTU) �" 19 1
the California Health&Safety Code,Stolons 25505,25533 and 25534. I v CM
understand that if the building does not currently have.meant,that It k my NEW RESIDENTIALMECH. SQ.Ff.
responsibility to notify the occupant of the mquirements which must be rrant V
prior to Issuance of a Certificate of Occupancy. Cl1u w6/9„p„asl
Owner or authorized agent Data ��Y WWy�1YgL1�fJ�
TOTAL: ISSUED BY. V(X' \VO,Js�tp
OFFICE COPY