22258 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY .
gnudln Project IdentlHcatlun PFR.wTNO.
buildingAddress: 22258
owe . Dr
ser ams: one: __WpI`=TR5V9Miri AL DAM
'
2511-'7,7q 1 CITY OF CUPERTINO-BUILDING DIVISION /
nactora Naa�mm�sfs4, SC
No APPLICATION / PERMIT.
SlT�S TN)ASM-Ir�f M4'�ue. BUILDING-ELECTRICAL.W-UMBING-MECHANICAL CATEGORY - CONTROL
Architect/Engineer. Lk.No:
t QTY ELECTRIC PERMIT FEE ' BUILDING PERMIT INFO'
Address:
LICENSED CONTRACTOR'S DECLARATION PERkBTISSUANCE Y-u 1:1 El
T hereby affirm that l am licensed under prwlsionso(Chapter 9(mmmena APPLIANCESRESTDENTAL ' - JOB DESCRIPTION
Ingwlth Section 7000)o(DIVlalon3ofthe Buslnessand PrefesslonsCode,and my 4
license is In f.111-fome and died. 290
.6Se PANEIS,
Date Contrector
ARCHILECTSDECLARATION 101-1000 AMI"'
q�q�uu O I undemtand my plans shall be used as public records. OVER 1000 AMPS SQ.Fr.FLOOR AREA S/SQ.FT.
F1 �j Licensed Professional SIGNS ELECTRICAL A L E D IPA
fn OWNER-BUILDER DECLARATION SPECIAL CIRCUIT/M1SC M P U T E
.0
Thereby-(firm that I -BUILDERexempt the DECLARATION
License Law lm Me
lo0owing....(Section 703 1.5,Business and Proleasans Code:Any city or /
O TEMP.MEIPRORPOLEINST. T(,
�� muntywhich rcquknapermit to mnatmd,alter,lmprove,dennlBh,orrepair
g any stmctum pdort.IB Bmance,also requlrestheapplleant(.such permltto p0/yER DEVICES
PJ O file a signed statement that he B limned pursuant to the provisions of the x��ataraslY�s
06 Contractor's License Law(Chapter 9(mmmenciagwlth Section7000)of Dlvl- VALUATION OS smn3o(the Business and Prafemloru Code)orthat he Is exempt therefromand SWIMMING I00L ELECTRIC
O the basis for the alleged exemption. Any violation of Sextan 7m15 by any /�O /1
applicant for a permit subjada the applicant to a civil penalty of not more than OUTLETSSWITCHESFIXTURES v
�j five hundred dollars(Will. -��,
R Ii
❑ NEW RESIDPNIIAL ELECTR 1,as owner of the properly,or my employees with wages as their sole RIES TYPE CONSTRUCTION
Compensation,will do the work and the structure B not intended or offered for
Osale(See,7044,Business and Proteavloru Code:The Corrado?.Lim.Law
$$ does not apply to an owner of property who builds or Improves t herron,and OCC.CROUIP RES.UNITS
whodees ms
such work hielrorthrough his own employees,provided that such
improvements arc not Intended orofferedforeale.If,however,thebulldingor TOTAL:
improvement issoidwlthln omyearotmmplatomtheowner-buliderwillhave
tl�urden of proving that he did not build or improve for purpose ofaakJ. QTY. PLUMBING PERMIT - FEE F1'OOD ZANE APN
u 4 as owner of the property,am exclusively conlratling with licensed
contract.to mruBudthe project(Sae 7011,Business and Professioru Code: PERMIT ISSUANCE ,
The Contractor.Lt...law don nd apply to an..at M propery,who ALTER-DRAIN&VENT-WATER(EA)
builds or Improvn thereon, and who contracts for such p(ojeets with a
m,ttBBrTadore)Boosted pursuant to the Contractors License Law. BACK FLOW PROTECT.DEVICE FEE SUMMARY.
LII am exempt under Sec. B&P C for this reawn
•
Owner DRAINS FLOOR ROOF,AREA,COND. SANITARY Y N Date RECENT
WORKMAN COMPENSATION DECLARATION re,
Of hereby affirm that I have a certificate of consent to self4omor a Iq%'IVRES PER TRAP SCIBOOL TAX Y N
RECFII+1 N
certilicateofWorkera Compewttonlnaunnce or a certifrcimpy,thereof(Sec.
MW,Lab CJ GAS EA.SYSTEM-1 INCAOUTLECS PARK FEE Y N
Policy It - RECEI'I N
'Com an GAEA.SYSTEM-OVER4(EA)
❑ Y B UI L DING D I VISI ON FE ES
CS ertfied copy herebytehed,
CREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
❑
Certified py B filed withh the city Inspection division.
CERTIFICATE OF IXEMFTION FROM WORKERS' CREASETRAP PAID
COMPENSATION INSURANCE
(rhissedlonneed not becompihted ifthepermit kferonehundrcddollara SEWER-SANITARY-STORM EA.200FT. Date Rgeel t#
($1 W)mlesa WATQtIiEATFR W/VENT/ELLCTR ENERGY FEE Y N
Imrtifyt at the performance oflhework forwhlcb this permit is Broad,
I shag note p y any person l manner o as trt publed to the WA.f.Qt SYSrFA1/.I.RFA.ONC PAID
Worken'Co nsati.n wso I mil.Data ;
O Z Applkan NEW RESIDE-MAL PLMB. SQFr. Date Rene] t#
Z O NOTICE70 PL he a Cupar Cti..provisions
c4tie Labor
H should bemmxa cath¢Wor Campematlon provbleru ofthe Labor TOTAL:
W Code,you mu.t(.rthwlth comply withsuch provkiom or this permlbhall be
W > deemed revoked. BUILDING .. 3 ,o
pCONSTRUCTION LENDING AGENCY SEISMIC FEE
1 Ihereby
af(Irmthattherc Ba cemtmctlon lending agency for the perform ELECTRIC FEE
Z ante of the work(or which thispermit Is Eased(Sec.3097,Cls.C.) TOTAL:
'
IJ O Lender'.NamePLUMBING FEE
Lender'.Addmaa QLY, MECHANICAL PERMIT FEE MECHANICAL FEB
OW ImAilylhat I have read thkapplicationand statethat theabove Information
6 Bmmoot.Iagreetomerplywlth all cityand countyordinanm and statelaws PERMIT ISSUANCE FEES PAID:
N rel (o building construction,and hereby autharlu representatives otthB
r U) i to terupontheabove-mentioned property for impaction purposes. ALTERORADDTOMECH.
_ c (We) gun to rave,Indamnly and keep harmless the City of Cupertino Date Recei t#
a ainst abilltles,' ots,mats and expenses which may lnanywayaccrue AIR HANDLING UMT(TO 10,000CFM) SUBTOTAL' -
a 1 old city sten uence olthegn,mingofthispertnit
AIRHANDLING UNiT(OVER 1o,0D0CrhU - CONST RUCTION TAX
sgN crap /c mads .Da EXHAUST Hoop(w/Doers CONSTRUCTION TAX PAID: '
OUS MATERIALS DISCLOSURE
:Wllltheappllcant to to building occupant store or ha rad Is hazardous HEATING UNIT(TO1 Ol BTU)
material as defined by the Cupertino Munlclps l Code,Chapter 9.1 2,and the _ Date Recel t#,
Health and Safety Cede Section 2S532(a)2 HEATING UNIT(OVER 100,000 BTU) TOTAL: S
❑Y. No
Willthe applicant or iurebullding occupant use equipment otdevices VENTILATION FAN(SINGLE RESID)
ISSUANCE DATE
which coot hazardous air mnnmlmnta as defined by the flay Area Air
Quality Management District? - BOILER-COMP OHPOR 100,M BTU) P N•+yf +
Yea ❑No
read the hazardous materials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,DM BTU)' ��•, l nl1�
t Calif. la lleahh&Safety Code,Sections 25505,75533 and 25534. 1 ro ✓ �s7D
u dertan that if the bullding don notmrzently havealenan4 That llBmy NEW RESIDENTIAL MECH. SQ.FT
r one' Illy to tonally the Occup io of the requirements which most be me,
P Issuance Ificeteof0mupancy. _ u`1
Own tet to O 9.L
g(qr of,
Of. ISSUEDBY:� uTOTAL:
OFFICE COPY
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