22584 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Building Protect identification PERMIT NO.
Building Address: _ /'11^t�L�
�2yjk� L�uPR ANN C-T, GG�YJ8
wt aares one:
r A A
CITY OF CUPERTINO-BUILDING DIVISION
Contra"or " mel k.N°v. APPLICATION I PERMIT '
8421v15 BUILDING-ELECTRICAL-PLUMBING-MECHAMCAL CATEGORY CONTROL
Architect/Engineer. Lk.No:
t 4TY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: /
.
LICENSED CONTR DECLARATION '
PERMITISSUANCE CD
y m,'hatlamunder
rroalmaofr9(wmmmc- APPLIANCES-RESIDENTIALIngwithSd..700)o(Dl .im3oftheBueinsmAProfes9meCode,end mylcense iein full d offeet
ESC ON
❑
PATOIS Ski� 1
Lken C Lk.N UP TO 2DU ANTS
Date Contractor_
ARCHITECT`S DECLARATION 201-1000 AMPS
aO ZpOC Iu tat ryp aha h urs;d es public records. OVER 1000 AMPB ' SQ.SIE Rn �A 5/SQ.Ff.
U Licensed I r�embm� mil _ SIGNS ELECTRICAL -COMP
Xe {� (L/ �
OWNER-BUILDER DECLARATION SPECIALCIMT/MISC „/, ® ppp
Ihereby affirm that l am exempt from the Contractor's License Law for the M ITER
o4 cmntfollowng reason whichrquim foe? tt,Bueln d,.I Professions
emle knycilyorr �P METER OR POLE INST. � „/��
pz countywhkhpriortesapermne,comtmuiresthe applicant
forsch,orrepatr N��
.any atrocNre statement
itsthat he Is alcensed pursuant
to the
provisions
of t e POWER DEVICES 'CA
file a actor's statement that he t r 9(commencing
ening it the provision of the .
Ow Contractor's License Law(Chapter9 Comm ening with Section herefofIXvI-
30 SWI.IMINC POOL ELECTRIC
alon3o(the Buelneemd Pro(eelov Code)orthat Meta exempt lKerefromand VALUATION
the basis for the alleged exemption. Any violation of Section 76715 by myGDILETSSVJITGHFS-HXTDRFS ��- 8
Oapphcantfora permBsubjectstheapplicanttoa civil penalty ofnct morethan �
five hundred asrowner ofthears pro _ NEW RESIDENTIAL RLECTR SQFT. STORIES TYPE CONSTRUCTION
�n ❑I,as owner ll of ework yrs or he employee with wages r[herr sole
wk(5ce. 0Kion,Business and k,andthestmde:TheC Intendedo icark,tlw
for
O dale(Sec. pply to Businessand
property
Cade:TheCimproves Wcence Law
daesnotsoch loan owner of(prough his
enempbuilds or improveseted thatms,and OCC.GROUP RFS.UNITS
whodoeeauchworkhimsegorthraugh hieawnemployeea,providedthatsuch
Improvements are not Intended or offered for sale.If,however,the building or TOTAL:
i provementlssoldwilhlnoneyearofcompleion.theowner-bullderwfllWve
t rdenof peovingthat he did not build or impress forpurposeofsaleJ. PLUMBING PERMIT FEE FLOOD WNE APN
"L as owner of the property,am exclusively contracting with 14xnxdpFy IT ISSUANCE �^�C�
contractors to construct the project(Sec 7094,Business and Professions Code:
The Contactors e License Law donet apply to an owner of property who ALTQt-DRAIN&VENT-WATER(EA)
Wilda or improve thereon,and who contracts for ouch project,with a ,
to➢t..ttsmarts)licensed pursuant to the Contractor's License Law. FEE SUMMARY
151 am exempt under Sec. B&P C for this reason BACK FLOW PROTECT.DEVICE
OUTSIDEFEES
• Owner DRAINS F7-DDIL ROOF,AREA,COND. SANITARY Y N
ate RECEIPT N
ter/ WORKMAN COMPENSATION DECLARATION FD(TURES PER TRAP SCHOOL TAX Y� N
�1 nereby ori m that I eS a a mrtlfnn of consent d apythemo ora RECEIPT M
381Lmaifiad,ofWorkem'Compersatlonlrmurance oracertifled copy thereo((Sw. GAS EA.SYSTEM-1 INC.40UTLEIS 2 (� PARK FEE Y', N
3X00,LebC �m�
Poliry X_ _ !l77J - GAS EA, RFGEI'I'N
Com anv BUILDING DIVISION FEES
5?Certiied copy 6 herebyth the cid. GREASE/INDUSTRL WASTE INTERCEPTOR PLANCHECK FEE
�CertUied ropy is(Iced with the city inspection divlelon.
CERTIFICATE OF EXEMPTION FROM WOR KERS' GREASE TRAP PAID
COMPENSATION INSURANCE Date Recei tri
(Chia section need not becompleted INhe permit b torone SEWER-SAMTARY-STORM EA.200FC..hundred dollars -
($100)or Icertifyth WATER HEATER W/VENT/ELECTR ENERGYFEE Y' N—
I
certify that emba ploy
anhe perf.I.anyod cavohe work an as to h this pesubjecrmit is leaved, _ —
I shag not employ any person in any raaer n e to beroire'subject to the WATER SYSTM/CREATING
Workers'Compeneation lJsys of California.nDate PAID
ZZ Applicant NEW RESIDENTIAL PI.MB, SQ.FT. Date Re i tN
Q NOTICE TO APPLICANT.If,offer making this Certificate of Exemption,you
Fshould become subject to the Workera''Compnsatlon provisions of the Labor TOTAL:
N Code,you must forthwith comply with such provisions,&this permit shall be BUIL l
LII > deemed revoked.
CL CONSTRUCTION LENDING AGENCY SEISMIC FEE l bu
Z Ihereby aHlrm that there is a construction lendlegagency for the perform- TOTAL: ELECTRICFEE'
ance of the work for which this permit Ia Issued(Sec.3097,Civ.C.)
O O Lenders Name PLUMBING FEE 00
LL F Lender's Address QTY, MECHANICAL PERMIT FEE MECHANICAL FEE
OW I certlfythatl have read this applicatlonand statelhatthe above information
ll is comed'I agree to comply with all city and county ordinances and state laws PERMITISSUANCE FEES PAID:
relating to building mmtruction,and hereby authorize representatives of this
F- Z cityto enter upon the above-mentioned property for Inspection purposes. ALTERORADDTOMECH.
Date Reeei to
V — (We)agree to save,Indemnify an d keep harmless the City of Cupemno P
against liabilities,judgments,mob and expenses which may In anyway aceme AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
against said City icans en the granting of this permit. � q
MR HANDLING UNIT(DYER 10,1100CFM)' CONSTRUCTION TAX
Ngnatolineof Appl rat/C ractor Dab EXHAUSTHOOD(W/DUCT) ' CONSTRUCTION TAX PAID:
HATAR OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(10 100,000 BTU)
material as,defined by the Cupertino Municipal Code,Chapter 9.IZ and the Date Recei tp
Health and Safety Code Sectio,25532(1)7, HEATING UNIT(OVER 100,000 BTU) TOTAL:
- V
F1 Yea N No
Will the applicant or future beilding occupant use equipment or devices VENTILATION PAN(SINGLE REBID) ISSUANCE DATE
which endt hazardous air contamimnb as defined by the Bay Area Air
a lity Management District? BOILER-COMP(3FT'OR 1D0,000 BTU)
Yea yI�No
ave readthe hazarroua nulerlals requiremFR ents under Chapter 6.95 of BOILER-COMP 100,000 BTU)
W Rsm11u( }
the fmfa Health&Safety Code,Sections 25505,25533 and 25534.I
understand that if the building does not currently have a tenant,that it is my NEW RESIDENTIAL MECH. SQ.FT. �I,WW QQ e�n
responsibility to notify the occupant of the requirements which=at be met i.4 N �iJIPRp
prior to issuance of a Certificate of Occupancy,
t
Ownerorauthorized agept Date - TOTAL: ISSUEDBY: j �
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