22015 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
BuildingProtect Identification PERMIT NO,
Building Address: - - 5 a - 2201 5.
.�: dne.
sone . r CITY OF CUPERTINO-BU ILDING DIVISION
cnntndnrgN.m.: APPLICATION / PERMIT
NTROL M
vl C .S��v BUILDINC-EL TRICAL-PLUMBINGMECHANICAL CATEGORY CO
Are},Itect/Englrleer. Lk.N.
QTY ELECTRICPERMIT FEE BUILDING PERMIT INFO
Add. PERNETISSUANCE `A-110
LICENSED CONTRACTOR'S DECLARATION
I hereby&film that l am Uc.sed under provisions of Chaptcr 9(comencru, APPLIANCES-RESIDENTIAL JOB DFSCRI''fION
ingwith Sectlon7000)of Dlvblon3ofthe BuN.euand Prof IonsCode,anlmy ��
11...Is In full forte and affect. PANELS
LI...ClamV_Li 33 �
Date Cantrectdr201-1000 AMPS
Tr-ARCHITECT`S C TIO OVER 1000 AMP5 $Q.FC.FLOOR ABPA S/SQ.FI.
MO O I understand my plan.hall housed.public records
Licensed Pmf,.I..l SIGNSELECTRICAL
OWNER-BUILDER DECLARATION
In ES SPECIAL CB2CUIT/MISC
I„ owing hereby
rmson. Sthat lam31.5,5from the Contractor's Code:
Law fee the Zoq�y (m0owln rcason.(Section 70815,Buslnem and Profembv Code:M d or
FZF,3 B o ty h]NP.METER OR POLE INST.
� oarntywhich requirnapermlttomruwcl,ilter,hnprove,demollahorrepalr
any structure prortoltsbeuance,also requdethe applicant forsuch permit to POWER DEVICES
0r..Igned statement that he Is Boensed pursuant to the provldoru of the
Contractor's License Law(Cha er9(commendn with Section 70 W)of LTM.
3Qe' sion3ofthe Bueinessand Prf.i..Code)orthatthebewm therefmmand SWNtMINC(POOL ELECTRIC Kc
VALUATION
the taxis for the surged exemptin. Any violation of Section 70315 by any OUTLETSSWITCHFSFIK'NRFS �Q ••appUnntforaper tsubie theapplkanttoadvilpemltycfna =.than tflv�undreddollan(S50)). NEW RESIDENTIAL ELECTR_ SQ. STORIES TYPECONSTRUCTION
�n I,
as
owner of the property,or my employees with wages as their sole
rompensatlon,willdothe work and thestrodure b net intended or offered for
Osale(Sec.7044,Business and Professions Code:The Contractors License law
$ docs net apply to an owner of property who Wilds or improve,thereon,and OCC.GROUP RIS.UNITS
whodoeasuch work himself or through hisown employee.,provided that such
improvements om not Intended oroffered forsile.IL lumaver,thebuilding ur TOTAL:
Improvementis oidwthinoneyesrofcompletion,theawner-bu0derwlllhave
tl ura'onfpmWngthat he did notWud orimprove for purposeof.ale.). QIT• PLUMBINGPERMIT FEE
I_I FLOOD ZONE APN
I.as our of the property,am eacldwy,..trading with Ikenxd
u
contractors to.rtriruct the projeet(See 7061,Business and Profenkm Code: PERMIT ISSTIANCE 7
'
The Commerce.License Law does not apply to an owner of property who ALTER-DRAIN 4 VENT WATER(EA)
A`
Wads or Improves thereon,and who.Mads for such ptojecta with a
cq�3f+aor(.)Ucensed pureuanttotha Contractors Lken.La w. BACK FLOW PROTECT.DEVICE FEE SUMMARY
LJ I am exemia under Sec B 6 p C for this reason
OUTSIDE FEES
DRAINS.FLOOR,ROOF,AREA,COND. SANITARY Y N
. Owner Date RECEIVE M
WORKMAN COMPENSATION DECLARATION FIXTURES-PER TRAP SCI{OOL TAX Y N
❑I hereby affirm that I have o certificate of consent to copy
theme ora - RECEIPT M
certificate of Workers'Comperoatlon Wurance oramrtlfled copy thereof 6ec. GAS EA.SYSTEM-1 INCA OUTLETS PARK FEE � Y N
3800,Lab CJ RECEIPT R
m a S .
Po - GAEA.SYSTEM-OVER LEA) -
Cmany 9L.l,Af,(,. OH,qt BUILDING DIVISION FEES
�Cedlled copy hereby furnished. CREASE/INDUSML WASTE INTERCEPTOR PLANCHECK FEE
edified spy is filed with the city Inspection division.
CERTIFICATE OF EKEMPION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE SEWER.SANITARY-STORM EA.2001T. Date. RCCcI tH
(Thlssection need nut becompletedlithe permit b oronehundred dollars P
(510( fthat
I certir(ify that WATER HFATERW/VENT/E.ECTR ENERGYFEE Y N
N the pedomxmceolthe work forwNeh this permit lased,
I.hall not employ any person In any manner an as to become subject to the WATERSYSTEM/TRFATINC
Workers'Compensation Law.of California. Date PAID
Z ZNOTlicant
ICE TO APPLICANT-.If,after making this Certificate of Exemption,you NEW RESIDENTIAL PLMB. SQFT. Date Recei til
F 0 should become subject to the Workers'Comperuation provisions of the Labor TOTAL:
W
Code,you=at forthwith comply withsuch provbloru orthb permit shall be
W j deemed revoked. N s
CONSTRUCTION LENDING AGENCY SEISMIC FEE - qC
a Z I hereby affirm that there b a mmmuctiun lending agency for the perform- TOTAL: ELECTRIC FEE L qt(55
O O
arse of the work for which this permit is issued(See 3097,Civ.CI I
Lander.Name /. PLUMBING FEE 4�
U. F Lendeh Address NLR't�-e� QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W I.dlfythatlhW
avereadtapph.h..and A.te thattheabovelnformati.
a Iscorrect.lagreetacomplywithaUdtyand...tyordinan.,and Attelaw. PERM171551LANCE FEES PAID:
} N relating to buildingcoruuuctlon,and herebyauthorize representatives ofthi,
city to enter upon the ahowmentbnedp rty for inspection purpose. ALTERORADDTOMECH.
Z Date Revel tH
_ (We)agree to uve,NdemNfy and n harmie»the City of Cupertino
agaWtltablWin,lads res sande .nwhichmayloanywaysocrue AIR HANDLING UNIT 901(%0WCFM) SUBTOTAL:
agalmtmid City ern g6the antmg of this permit p 1 AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
' Signature of Applicant/Contractor Data IXHAUS"TfI00D(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fuwu WUdingo pantatomorhandieharardous HEATING UNIT(TO 100,000 BTU), Date RBcel tN
material as defined by the Cupertino Municipal Code,Chapter 9.1Z,and the -
Hee❑allt,ansdSafetyCod Se Jioon 75532(a)7 HEATING UNIT(OVER 100,000 BTU) TOTAL:
WIII the upplkaMIture building occupant use equipment or devices VENTILATION PAN(SINGLE RESID) ISS ATE
which emit harardous air contaminants as defined by the Bay Area Air
Quality Management ISWct7 BOILER-COMP OPIP DR 1m,IXD BT[n
Yn No
haus read the hoz oux matedab Iremenb under Chapter 6.95 of BOILER-COMP(OVIR 100,000 BTU) APR ry
the Calilomr Health&Safety Code, .75545,75533 and 75534.1 '! fl
understand that i(lhebu0d gdonn gently have.temnL that it b my NEW RESIDENTIAL MECH. SQFT
resporol6ility lora occupant he mqulmmenls which must be met
pdmo a d1l are of panty.
L
Owner&authorired agent to ISSUEDBY:
TOTAL:
OFFICE COPY